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LEA  BROTHERS  &  CO.,  PUBLISHERS,  PHILADELPHIA. 


Th<?  Students'  Quiz  Scries. 


GENITO-URINARY 


AND 


VENEREAL  DISEASES. 


A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS. 


BY 

CHARLES  H.  CHETWOOD,  M.D., 

Visiting  Surgeon  Demilt  Dispenmry,  Department  of  Surgery  and  Genito-  Urinary 
Diseases,  New  York. 


SERIES  EDITED  BY 

BERN   B.  OALLAUDET,  M.D., 

Demonstrator  of  Anatomy,  College  of  Physicians  and  Surgeons,  New  York;  Visiting 
Surgeon  Bellevue  Hospital,  New  York. 


PHILADELPHIA: 
LEA  BROTHERS  &  CO. 


Entered  according  to  Act  of  Congress,  in  the  year  1892,  by 

LEA  BROTHERS  &  CO., 

In  the  Ofl&ce  of  the  Librarian  of  Congress,  at  Washington.    All  rights  reserved. 


Westcott  &  Thomson,  William  J.  Dornan, 

Stereoiypers  and  Electrotypers,  Fhilada.  Printer,  Philada. 


PREFACE 


In  preparing  this  work  as  a  "  Quiz  Compend,"  the  method  which 
the  author  has  endeavored  to  follow  is  to  present  the  various 
subjects  by  questions  which  would  be  apt  to  arise  in  the  mind 
of  the  student  and  practitioner,  and  to  form  the  answers  in  a 
conversational  and  descriptive  manner,  avoiding  terse  summaries. 
The  different  authorities  who  should  receive  recognition  are,  first 
and  principally,  Dr.  Edward  L  Keyes,  whose  exhaustive  works 
on  the  subjects  herein  treated  have  been  of  the  greatest  assist- 
ance. Other  works  which  should  receive  due  mention  as  refer- 
ences are  Professor  Ultzmann's  Genito- Urinary  Neuroses;  Sir 
Henry  Thompson's  Clinical  Lectures ;  and  Ashurst's  EncyclojpBtdia 
of  Surgery. 

In  delivering  this  little  work  into  the  hands  of  my  fellows 
with  its  merits  and  demerits,  if  it  only  succeeds  in  creating  a  more 
widespread  interest  in  Genito-Urinary  Surgery,  and  in  directing  at- 
tention toward  the  larger  works  on  this  subject,  it  will  have  attained 
at  least  one  of  the  objects  designed  for  it  by  the  author, 

CHAS.  H.  CHETWOOD. 

120  East  Thirty-fourth  st., 

New  York  City, 

June,  1892. 


CONTENTS. 


PAGE 

Anatomy  and  Physiology 17 

VENEREAL  DISEASES. 
Syphilis  :  Treatment  of  Syphilis ;  Infantile  and  Inherited  Syphilis  •       18 
Chancroid:  Venereal  Warts 32 

GENITO-UEINARY   DISEASES:  VENEREAL. 

Disease  of  the  Male  Urethra  :  Urethritis 37 

GoNORRHCEA  :  Treatment  of  Gonorrhoea ;  Gonorrhceal  Rheumatism  ; 

Gonorrhceal  Ophthalmia;  Stricture  of  the  Urethra;  Treatment; 

Internal   Urethrotomy ;    Treatment   of   Stricture  by   Divulsion ; 

Electrolysis  in  the  Treatment  of  Stricture ;  Choice  of  Treatment 

of  Anterior  Strictures  ;  External  Urethrotomy 40 

GENITO-URINARY   DISEASES :  NON-VENEREAL. 

Diagnosis 75 

Disease  of  the  Penis  and  Adjacent  Parts:   Epithelioma  of 
the  Penis ;  Balanitis  and  Posthitis ;  Phimosis  and  Paraphimosis ; 

Herpes  Progenitalis 79 

Cutaneous  Affections:  Pediculosis  Pubis 85 

The  Prostate  Gland:  Prostatitis;  Syphilis  and  Cancer  of  the  Pros- 
tate; Prostatic  Concretions  and  Calculi ;  Prostatic  Neuralgia  ...      86 
Diseases  of  the  Bladder:  Cystitis;  Atony  and  Paralysis;  Morbid 

Growths;  Cystoscopy;  Stone  in  the  Bladder 104 

Diseases  of  the  Ureters 130 

5 


6  CONTENTS. 

PAGE 

Diseases  of  the  Kidney  :  Anomalies ;  Renal  Calculus ;  Pyelitis 
(Pyonephrosis);  Surgical  Kidney;  Tuberculosis  of  the  Kidney; 
Tumors  of  the  Kidney;  Cancer  of  the  Kidney;  Cysts  of  the 
Kidney ;  Hydronephrosis ;  Syphilis  of  the  Kidney  ;  Nephrorraphy 
and  Nephrotomy ;  Nephrectomy ;  Abnormalities  of  the  Urine  .    .    131 

Diseases  of  the  TesticiiE  and  Cord  :  Hsematocele ;  Hydrocele ;  Sper- 
matocele ;  Hydrocele  of  the  Spermatic  Cord  ;  Orchitis  ;  Epididy- 
mitis ;  Tuberculous  Disease  of  the  Testicle ;  Syphilitic  Testicle ; 
Tumors  of  the  Testicle;  Neuroses  of  the  Testicle;  Impotence; 
Anomalies  affecting  the  Semen  ;  Nocturnal  Emissions ;  Sperma- 
torrhoea; Varicocele ,    146 


GENITO-URINARY  AND  VENEREAL  DISEASES. 


ANATOMY   AND   PHYSIOLOGY. 

What  are  the  male  generative  organs? 

The  penis  and  glands  of  the  urethra^  the  testicles  and  appendages. 

What  is  the  first  act  essential  to  generation? 

Coitus. 

What  organs  in  the  male  accomplish  it,  and  are  necessary  to 
make  it  fruitful? 

The  testicles  primarily,  which  make  the  vital  elements  of  the 
seminal  fluid,  the  vesiculse  seminales,  reservoirs  in  which  the  semen 
is  stored  until  expelled  through  the  ejaculatory  ducts  opening  on 
the  floor  of  the  prostatic  urethra  ;  the  p>Tost  te  and  smaller  glands 
opening  into  the  urethra,  which  contribute  a  mucous  vehicle  for 
the  semen  ;  the  penis  during  the  phenomena  of  the  erection  and 
ejaculation. 

What  are  the  urinary  organs? 

The  kidneys  and  their  excretory  ducts,  the  ui^eters,  the  hladder.^ 
and  the  urethra. 


VENEREAL    DISEASES. 

What  is  a  venereal  disease? 

One  which  is  acquired  during  the  act  of  sexual  intercourse,  or 
the  origin  of  which  is  referable  to  this  source. 

What  are  the  external  genitals? 

The  penis  and  scrotum  in  the  male,  and  the  mons  veneris  and 
vulva  in    the  female. 

2— G-u.  17 


18  SYPHILIS. 

What  venereal  diseases  commonly  make  their  appearance  here  ? 

Syphilis  in  its  different  stages,  notably  as  its  primary  lesion  the 
chancre,  chancroid  (or  the  so-called  soft  chancre),  venereal  warts, 
and  pediculi. 

What  other  diseases  not  essentially  venereal  involve  these  parts  ? 
Inflammation   affecting  the  glans   penis    and    adjacent   mucous 
membrane,  termed  balanitis,  herpes  progenitalis,  cutaneous  affec- 
tions, and  tumors. 

What  anomalies  of  the  external  genitals  occur  ? 

Anomalies  of  size,  defective  development  of  the  penis,  absence 
of  and  double  penis ;  hypospadias  and  epispadias,  both  of  which 
may  be  only  slight  or  may  involve  the  entire  external  genitals. 

SYPHILIS. 
What  is  syphilis? 

Syphilis  is  a  general  disease  or  dyscrasia  of  the  blood,  which  in 
its  acquired  form  appears  first  externally  in  its  primary  lesion, 
called  chancre,  which  may  be  followed  by  profuse  or  only  isolated 
outward  manifestations  in  its  later  stage. 

How  is  syphilis  transmitted  ? 

Generally  during  sexual  intercourse,  but  in  any  manner  by 
which  the  virus  from  one  source  is  brought  in  contact  with  an 
abraded  or  mucous  surface  of  another. 

Into  what  stages  is  syphilis  generally  divided  ? 

Three :  primary,  the  stage  of  infection  and  incubation  and  the 
period  of  the  primary  lesion  called  the  chancre ;  secondary,  the 
stage  of  superficial  lesions  of  the  skin,  mucous  membrane,  and 
lymphatic  glands  ;  tertiary,  the  period  of  deep-seated  and  destruc- 
tive lesions. 

How  long  after  the  absorption  of  the  syphilitic  virus  does  the 
primary  lesion  or  chancre  appear? 

Generally  after  an  interval  of  about  three  weeks.  Periods  of 
longer  and  shorter  duration  occur,  but  this  may  be  called  the 
average. 

During  this  period  do  any  symptoms  occur  to  indicate  the  pres- 
ence of  the  disease  ? 

No. 


CHARACTEEISTICS.  19 

What  happens  at  the  point  of  infection  during  this  time  ? 

After  perhaps  a  temporary  soreness  or  irritation,  which  is 
mechanical,  the  spot  resembles  in  every  way  the  surrounding 
tissues. 

Where  does  the  chancre  make  its  appearance? 

At  the  point  where  the  virus  has  been  absorbed. 

Is  its  situation  restricted  to  any  one  portion  of  the  body  ? 

No  ;  it  may  attack  any  part  under  the  conditions  necessary  for 
its  infection. 

Where  is  the  most  common  seat  of  venereal  chancre  ? 

On  the  mucous  membrane  behind  the  corona  glandis. 

Is  the  chancre  a  single  or  multiple  lesion? 

While,  as  a  rule,  it  is  more  apt  to  be  single,  as  many  points  as 
are  separately  inoculated  will  yield  the  same  number  of  lesions. 

Does  the  chancre  become  multiple  after  its  first  inoculation  ? 

No  ;  the  chancre  is  not  "  auto-inoculable."  Multiple  chancre 
occurs  from  separate  points  of  inoculation  at  the  time  of  exposure. 

What  is  the  first  appearance  that  the  chancre  presents  ? 

It  first  appears  as  a  small  papule  or  hard  pustule,  which  soon 
moistens  or  ulcerates. 

What  is  a  common  characteristic  of  syphilitic  chancre  ? 
Induration  ;  hence  the  name  "  hard  chancre." 

What  is  the  nature  of  this  induration  ? 

It  may  be  thin  or  parchment-like  under  the  chancre,  only  felt 
on  manipulation,  but  is  often  more  extensive,  when  it  is  easily 
distinguishable  by  the  eye.  It  is  situated  beneath  the  ulcer, 
does  not  shade  ofi"  into  the  surrounding  tissues,  and  is  freely 
movable. 

When  does  it  appear? 

It  may  precede  or  follow  the  ulceration  during  the  first  week. 

When  does  it  disappear? 

Sometimes  before  the  ulceration,  but  generally  outlasts  it  for 
several  months,  and  rarely  for  years. 


20  SYPHILIS. 

What   different    forms    may   the    chancre    assume   when   fully 
developed. 

First  and  most  frequently  it  appears  as  a  flat  erosion,  generally 
behind  the  corona  glandis  (when  venereal),  undermined  by  parch- 
ment-like induration,  which  sometimes  causes  it  to  protrude  farther 
than  the  corona  itself.  When  multiple  this  gives  it  the  appearance 
of  a  cartilaginous  band  with  ulcerated  surfaces,  glistening  and  red. 
It  may  appear  with  superficial  ulceration,  presenting  the  appearance 
of  a  split  pea,  with  slanting  edges  and  underlying  induration,  the 
discharge  being  purulent  or  sero-purulent.  The  "  Hunterian '' 
chancre  is  not  so  frequent :  it  appears  with  an  extensive  cartilagi- 
nous induration,  edges  of  the  ulcer  sloping  and  adherent,  not 
undermined,  and  having  a  funnel-shaped  appearance,  rounded  or 
oval ;  discharge  sero-purulent.  On  the  skin  the  chancre  often 
appears  as  an  indurated  tubercle  which  does  not  erode,  but  re- 
mains thus  until  it  scales  off  or  becomes  covered  by  a  crust. 

What  is  the  general  character  of  the  discharge  from  a  chancre  ? 

Serous  or  sero-purulent  and  sometimes  bloody — never  thick  or 
richly  purulent  unless  subjected  to  great  irritation. 

What  is  the  duration  of  the  chancre  ? 

From  a  couple  of  weeks  to  several  months,  the  induration 
remaining  after  the  sore  has  cicatrized. 

What  is  the  nature  of  the  scar  which  it  leaves  ? 

It  varies  according  to  the  nature  and  depth  of  the  sore.  Some- 
times there  is  none  at  all.  If  present  it  first  undergoes  a  period 
of  pigmentation,  commencing  with  a  venous  hue,  which  after  dark- 
ening ultimately  bleaches  out,  and  the  scar  becomes  whiter  than 
the  surrounding  tissues. 

What  are  the  complications  liable  to  accompany  chancre  ? 

Inflammation,  chancroid  (mixed  sore,  see  p.  32),  phagedaena  and 
gangrene,  vegetations,  bubo,  and  lymphangitis. 

What  is  a  mixed  chancre? 

Where  chancre  and  chancroid  (the  local  venereal  ulcer)  become 
inoculated  and  develop  in  the  same  spot. 

When  a  syphilitic  chancre  becomes  inoculated  with  chancroidal 
pus,  what  happens? 

The  ulcer  seems  to  take  on  the  character  of  chancroid,  while  the 
induration  remains. 


SYPHILIS.  21 

When  a  chancroid  is  inoculated  with  syphilis,  what  happens? 

The  ulcer  remains  unchanged,  but  after  a  period  of  incubation 
induration  sets  in.  If  they  be  simultaneously  inoculated  at  the 
same  spot,  the  chancroid  first  appears,  and  after  a  variable  period 
of  incubation  the  induration  sets  in.^ 

What  is  syphilitic  bubo? 

Enlargement  and  induration  of  the  lymphatic  glands  adjacent 
to  the  seat  of  the  chancre.  (The  general  glandular  enlargement 
appears  later  as  a  symptom  of  the  secondary  stage.) 

By  what  are  bubos  produced? 

By  absorption  of  irritating  substance  from  the  chancre  and  con- 
stitutional debility. 

What  situations  of  the  chancre  would  affect  the  inguinal  glands  ? 
Penis,  groin,  scrotum,  perineum,  anus,  etc. 

What  glands  are  affected  in  chancre  of  the  lip  ? 
The  submaxillary  lymphatic  glands. 

What  is  the  general  character  of  these  glandular  enlargements  ? 

They  are  hard,  freely  movable,  rarely  painful,  and  vary  in  num- 
ber and  size.  Sometimes  there  is  one  very  large  gland,  but  more 
often  a  chain  of  hard  lumps.     They  may  be  unilateral  or  bilateral. 

When  does  this  glandular  induration  occur? 

During  the  second  week  of  chancre. 

Is  this  condition  of  glandular  enlargement  regularly  present  ? 

Yes  ;  it  is  one  of  the  diagnostic  symptoms  of  syphilis. 

Does  suppuration  ever  occur  in  these  glands? 

Practically,  never.  When  present  it  is  referable  to  direct  vio- 
lence or  inflammation  of  the  chancre  in  an  undermined  consti- 
tution. 

What  is  syphilitic  lymphangitis? 

It  seccompanies  chancre,  and  is  an  induration  of  the  lymph-ves- 
sels which  are  adjacent  to  it,  distinguishable  by  hard,  knotty  cords, 
which  are  not  sensitive  and  are  not  marked  by  a  reddened  skin. 

*  The  secretion  of  such  a  sore  is  capable  of  transmitting  chancroid  alone, 
as  the  pus  of  chancroid  is  more  virulent  than  that  of  any  other  venereal 
ulcer. 


22  SYPHILIS. 

On  what  does  the  diagnosis  of  syphilis  depend  when  that  of  the 
sore  is  not  established? 

On  the  appearance  of  a  syphilitic  eruption  indicating  the  pres- 
ence of  a  general  and  not  local  disease,  which  syphilis  is  and  must 
be  without  exception. 

We  have  divided  the  later  appearance  of  syphilis  for  conveni- 
ence and  from  usage  into  secondary  and  tertiary  stages. 

Is  there  any  clear  line  of  demarcation  between  them  ? 

No  ;  the  disease  is  constitutional  from  the  start,  but  the  first 
symptoms  of  general  syphilis  begin  with  the  so-called  secondary 
stage. 

Is  there  an  interval  between  the  first  and  second  stages? 

Yes ;  a  so-called  "  second  stage  of  incubation,"  lasting  on  an 
average  forty-three  to  forty-five  days. 

How  long  does  the  period  last  during  which  these  secondary 
symptoms  appear? 

From  a  year  to  eighteen  months — sometimes  two  years  or  more 
— with  various  exceptions  on  both  sides  of  the  rule. 

Are  there  any  prodromal  symptoms  to  the  secondary  stage  ? 

Yes ;  about  a  week  or  ten  days  before  the  eruption  appears  the 
patient  passes  through  a  febrile  stage  of  a  variable  character,  some- 
times coming  on  as  a  simple  febricula.  in  other  cases  as  a  malarial 
paroxysm,  remittent  or  intermittent. 

At  this  period  of  the  disease  what  is  apt  in  the  appearance  of 
the  patient  to  indicate  the  presence  of  a  constitutional  dis- 
ease or  cachexia  ? 
A  sallow  and  anaemic   complexion  and  a  general   condition  of 

malaise. 

Of  what  does  this  cachexia  consist  ? 

A  hydraemia,  or  a  diminution  of  the  red  blood-corpuscles  in  the 
blood. 

What  is  the  general  term  applied  to  syphilitic  eruptions? 

Syphilides. 

Mention  the  different  forms  these  syphilides  assume  during  the 
secondary  stage. 
Erythematous,  papular,  vesicular,  pustular. 


STAGES.  23 

What  general  characteristics  do  they  usually  present? 

A  general  absence  of  itching  and  pain,  appearing  first  in  a  livid 
hue,  later  becoming  pigmented  (presenting  a  characteristic  coppery 
color),  and  finally  disappearing  white. 

What  general  difference  is  there  between  the  histories  of  the  early 
and  late  eruptions  ? 

Early  eruptions  tend  to  be  superficial  and  general  ;  the  later 
tend  to  appear  in  patches,  and  affect  the  cutis  vera.  These  patches 
generally  take  on  a  characteristic  rounded  form. 

What  other  affections  accompany  the  early  outbreaks  of  the  sec- 
ondary stage? 

The  phenomena  of  syphilitic  fever  which  have  already  been 
mentioned — alopecia,  headache,  and  pains  in  the  joints  and  bones, 
which  are  worse  at  night ;  general  glandular  swellings,  iritis,  sore 
throat,  and  mucous  patches  in,  upon,  or  around  the  natural  orifices. 
The  latter  comprise  the  syphilides  of  the  mucous  membranes. 

What  different  forms  do  these  syphilides  of  the  mucous  membranes 
assume  ? 

Like  those  of  the  skin,  they  are  divided  into  superficial  and  deep 
lesions,  the  latter  appearing  late  in  the  secondary  and  during  the 
tertiary  stage. 

Early,  they  appear  as  a  general  congestion  or  erythema,  which 
may  or  may  not  be  accompanied  by  "  mucous  patches  " — small 
glistening  whitish  spots  not  properly  called  ulcerations.  As  the 
disease  progresses  these  patches  become  infiltrated,  and  finally 
may  break  down  and  form   real  ulcers. 

The  late  forms  comprise  the  ulcerative  syphilides  of  mucous 
membranes,  which  result  from  the  breaking  down  of  a  "  gumma  " 
formed  in  the  submucous  tissue.  The  so-called  gumma  appears  as 
a  brawny  swelling  or  tubercle  in  the  soft  parts,  showing  a  tendency 
to  destruction,  and  soon  breaks  down,  after  which  it  is  liable  to  be 
mistaken  for  chancroid.  The  history  of  the  case  may  assist  in 
clearing  up  the  diagnosis,  which  is  settled  by  the  use  of  anti- 
syphilitic  medication. 

When  does  iritis  occur,  and  what  does  it  consist  of? 

Possibly  within  a  few  weeks  or  months  ff)llowing  the  primary 
lesion,  or  as  an  accompaniment  of  the  later  phenomena  of  the  sec- 
ondary   stage.       There    is    nothing   distinguishing    in    syphilitic 


24  SYPHILIS. 

iritis,  it  having  the  same  symptoms  as  inflammation  from  other 
causes. 

The  symptoms  which  present  themselves  are  discoloration  of  the 
iris ;  smokiness  of  the  pupil,  which  may  be  irregular  ;  hyperaemia 
of  the  adjacent  structures ;  lachrymation ;  the  pupil  does  not 
expand  when  shaded  from  the  light,  and  is  inclined  to  be  small ; 
the  pain  may  be  situated  in  the  eyes — generally  located  around 
the  forehead  and  temple  or  anywhere  in  the  course  of  the  supra- 
orbital nerve.  There  is  an  exudation,  which  is  apt  to  be  more  or 
less  plastic,  but  may  be  simply  serous.  The  vision  is  impaired. 
It  may  occur  in  one  or   both  eyes  separately  or  simultaneously. 

The  prognosis  depends  upon  the  extent  of  the  lesion  existing  at 
the  time  treatment  is  resorted  to.  A  large  majority  of  the  cases 
under  proper  treatment  entirely  recover. 

The  treatment  comprises  the  general  constitutional  remedies  for 
the  disease  itself,  together  with  local  measures,  the  most  important 
feature  of  which  is  to  produce  complete  dilatation  of  the  pupil. 
This  is  effected  by  the  use  of  solutions  of  sulphate  of  atropine, 
2  gr.  to  the  ounce.  In  mild  cases  the  instillation  of  3  drops  of 
such  solutions  three  times  daily  will  suffice  to  overcome  any  adhe- 
sions which  may  exist,  but  it  must  be  repeated  with  greater  fre- 
quency according  to  the  obstinacy  and  extent  of  the  adhesions. 
Cold  compresses  may  be  applied  to  the  eye,  and  if  the  inflamma- 
tion is  very  high  leeches  may  also  be  used ;  but  the  most  efficient 
means  of  relief  will  be  found  in  procuring  a  rapid  constitutional 
effect  from  the  mercurial  remedies — namely,  by  hypodermic  use  of 
the  various  recommended  solutions,  by  inunctions,  etc. 

What  are  the  general  glandular  swellings  which  accompany  the 
secondary  stage? 

They  consist  of  an  indolent  engorgement  of  the  lymphatic 
glands  in  different  parts  of  the  body,  notably  the  post-cervical 
and  epitrochlear.  They  may  appear  simultaneously  with  the  first 
eruptive  lesions  or  prior  to  their  discovery.  Their  appearance  is 
very  useful  in  diagnosing  the  existence  of  the  syphilis  at  its  sec- 
ondary stage.     There  is  no  special  treatment  indicated. 

How  does  the  alopecia  which  accompanies  syphilis  appear? 

Either  as  a  simple  loss  of  hair,  general  or  in  patches,  of  the 
scalp,  eyebrows,  eyelids,  whiskers,  and  variously  over  the  whole 
body,  the  result  of  the  syphilitic  "  hydraemia,"   analogous  to  the 


CONCOMITANT   AFFECTIONS.  25 

same  condition  occurring  after  other  acute  causes,  such  as  fever, 
etc. ;  or  syphilitic  alopecia  occurs  as  a  result  of  a  seborrhoea,  where 
scabby  sores  are  formed  upon  the  scalp,  and  later  in  the  disease 
ulcerations  form,  in  which  case  the  lost  hair  is  not  renewed.  Gen- 
erally, however,  the  baldness  accompanying  syphilis  is  only  a 
temporary  affair. 

The  treatment  in  the  case  of  ordinary  baldness  is  the  use  of  a 
stimulating  lotion  and  proper  washing  or  shampoo  of  the  scalp 
at  about  weekly  intervals.  When  a  scalp  becomes  infested  with 
scabs  and  sores,  the  general  treatment  is  largely  to  be  relied  upon, 
while  the  scalp  may  be  kept  moistened  with  rags  wrung  out  in  mild 
solutions  of  bichloride  of  mercury,  on  general  principles  of  anti- 
sepsis. 

What   different  types   of  sore  throat  accompany  the   different 
stages  ? 

(1)  General  congestion  with  or  without  ulceration  ; 

(2)  The  chronic  congestion  and  thickening  about  mucous  patches 
or  atonic  ulcers ; 

(3)  Destructive  ulceration  (more  apt  to  accompany  the  later  or 
tertiary  stage). 

The  first  variety  is  an  early  secondary  symptom  and  an  accom- 
paniment of  the  early  syphilides. 

What  are  the  later  lesions  of  syphilis  ?  and  where  do  they  ap- 
pear? 

The  scope  of  these  lesions  is  almost  beyond  description.  They 
may  affect  any  organ  or  involve  any  tissue.  They  appear  upon 
the  face  of  the  individual,  or  they  lurk  secretly  within  and  involve 
his  internal  organs,  impairing  their  various  functions. 

It  would  be  impossible  in  a  compend  of  this  description  to  at- 
tempt to  enter  into  any  but  a  general  review  of  the  many  affec- 
tions the  causation  of  which  syphilis  enters  into.  There  is  hardly 
a  disease  in  the  whole  nomenclature  of  medicine,  of  mind  or  body, 
which  syphilis  cannot  enter  the  etiology  of.  It  affects  the  eye  and 
the  ear  in  their  different  portions,  and  impairs  or  destroys  the  func- 
tion of  these  organs  of  special  sense  according  to  the  extent  of 
involvement  and  the  part  it  invades.  It  enters  the  sheaths  of  ten- 
dons and  aponeuroses,  bursae  and  muscles,  causing  inflammation 
and  wasting  ;  and  in  the  tertiary  stage  the  so-called  gumma  may 
plant  itself  here,  as  it  may — and  does — in  almost  every  other 
tissue  of  the  body.     In  the  bones  it  is  inflammation  of  their  cover- 


26  SYPHILIS. 

ings  and  surroundings  or  substance,  and  again  as  a  gummy  tumor 
or  as  a  dry  "  caries ;"  and  so  on  through  the  digestive,  respiratory, 
circulatory,  and  nervous  systems,  invading  every  part.  The  later 
the  stage  of  the  disease,  the  deeper  and  more  serious  the  lesion, 
causing  symptoms  according  to  the  part  affected  and  the  function 
over  which  it  presides. 

TREATMENT   OF   SYPHILIS. 

What  is  the  general  treatment  of  syphilis  ? 

Medicinal  and  hygienic. 

Can  the  latter  be  effective  without  the  aid  of  the  former  ? 

No  ;  neither  should  be  depended  upon  alone. 

What  is  the  hygienic  treatment  of  syphilis  ? 

It  includes  all  the  ordinary  laws  of  health  and  living. 

Can  syphilis  be  aborted  by  excision  of  the  chancre  ? 
No. 

Can  the  consecLuences  sometimes  be  ameliorated  by  this  proce- 
dure ? 

No. 

What  is  the  best  method  of  local  treatment  ? 

Either  dry  dressing  in  the  form  of  such  powders  as  calomel, 
iodoform,  aristol,  dermatol,  etc.,  or  a  mild  astringent  lotion  contain- 
ing sulphate  of  zinc  or  diluted  nitric  acid. 

When  should  the  constitutional  treatment  for  syphilis  be  com- 
menced ? 
As  soon  as  the  diagnosis  is  established,  but  not  before. 

What  excesses  are  especially  detrimental  to  the  proper  treatment 
of  syphilis  ? 

Excesses  in  drinking,  venery,  and  work. 

What  is  the  so-called  specific  treatment  of  syphilis  ? 

It  consists  in  the  judicious  use  of  some  preparation  of  mercury 
combined  with  iodine.  The  consideration  of  this  specific  treatment 
is  divided  into  the  treatment  of  early  and  of  late  syphilis. 

What  is  the  proper  medicinal  method  of  treatment  to  be  pursued  in 
syphilis  as  soon  as  the  diagnosis  has  been  established  ? 

The  tonic  treatment,  which  consists  in  the  continuous  administra- 


TREATMENT.  27 

tion   of  small   doses  of  mercury  during  the  whole   period  of  the 
syphilitic  era. 

What  is  the  best  method  of  starting  the  patient  on  the  career  of 
the  tonic  treatment  of  syphilis  ? 
The  protiodide  of  mercury  is  the  best  form  to  begin  with,  com- 
mencing with  1  centigram  (gr.  -i-)  at  a  dose,  and  ordering  this  to 
be  taken  three  times  a  day,  to  be  increased  1  centigram  every  day 
until  the  physiological  effects  of  the  drug  are  felt,  such  as  colicky 
pains,   diarrhoea,   and  pains  in  the  mouth   experienced  in   eating. 

After  such  symptoms  appear  what  is  the  proper  method  to  pursue  ? 

By  halving  the  dose  which  has  procured  such  uncomfortable 
symptoms  the  tonic  dose  may  be  determined,  and  in  most  cases  will 
be  found  to  be  the  proper  amount  of  mercury  to  be  taken  through- 
out the  disease. 

If  a  case  of  syphilis  appears  for  treatment  later  in  the  career  of  the 
disease,  and  the  tonic  treatment  is  not  chosen  or  not  home, 
what  general  plan  of  treatment  may  be  laid  down  ? 

Early  in  the  secondary  stage  some  preparation  of  mercury  may 
be  given,  either  alone  or  combined  with  a  preparation  of  iodine. 
Later  in  the  secondary  stage  the  iodine  preparation  has  its  special 
indication,  and  later  still  in  the  disease,  where  the  lesions  are  deep 
and  serious,  the  iodine  preparation  alone  is  to  be  relied  upon  for 
rapid  and  active  work,  the  mercury  to  be  taken  up  after  decided 
effect  has  been  produced  by  the  iodide. 

What  are  the  different  methods  of  administering  mercury  ? 

By  the  stomach,  locally,  by  inunction,  fumigation,  and  by 
hypodermic  injection. 

By  the  Stomach. — It  is  given  in  pill  form  as  the  protiodide. 
This  is  sometimes  not  well  tolerated  on  account  of  producing  pain 
and  diarrhoea.  The  bichloride  is  generally  well  borne,  and  may  be 
given  in  solution  with  a  preparation  of  iodine.  The  "  gray  powder  " 
(hydrargyrum  cum  creta),  or  "  blue  mass "  (massa  hydrargyri) 
is  also  used,  or  the  biniodide  may  be  given  in  place  of  the  bi- 
chloride in  combination  with  an  iodide.  In  selecting  a  preparation 
different  cases  will  be  found  to  have  individujil  peculiarities. 

Locally. — Mercury  is  used  for  the  treatment  of  local  lesions, 
and  its  use  often  spares  excessive  internal  dosing,  and  is  a  decided 
adjuvant  to  the  latter  measures.  The  superficial  cutaneous  lesions 
require  no  treatment  unless  appearing  where  they  may  be  seen,  as 


28  SYPHILIS. 

on  the  hands  or  face.  The  different  preparations  which  may  be 
used  for  the  ulcerative  and  moist  lesions  are  the  oleate  of  mercury, 
5  to  10  per  cent. ;  the  white  precipitate  ointment  (hydrarg.  am- 
moniat.)  in  equal  parts  with  zinc  ointment  or  of  milder  strength  ; 
solutions  of  bichloride,  from  1  to  4  gr.  to  the  ounce  of  water,  with 
a  little  glycerin,  and  as  a  dry  powder  calomel  is  used.  Iodoform  is 
often  found  useful  on  the  ulcerative  patches,  or  a  little  of  it  may 
be  added  to  the  combination  of  the  white  precipitate  and  zinc 
ointments. 

By  Inunction  mercury  often  proves  more  efficient  than  by 
other  means,  as  any  possible  irritation  to  the  stomach  is  avoided 
and  its  use  is  thorough  and  efficient.  The  full  physiological  effects 
of  the  drug  can  be  obtained  by  this  means.  The  oleates  have  the 
objection  of  causing  a  great  deal  of  local  irritation.  This  method 
may  be  practised  either  by  the  use  of  mercurial  ointment,  which 
is  kept  constantly  in  contact  with  different  tender  surfaces  of  the 
body,  being  moved  from  one  point  to  another  as  irritation  arises,  or 
by  that  method  which  is  practised  at  the  Hot  Springs,  and  which  is 
given  in  the  following  manner :  The  patient  first  takes  a  bath  and 
is  well  rubbed  by  an  attendant,  after  which,  sitting  astraddle  a 
chair,  the  attendant  rubs  freely  and  vigorously  with  a  circular 
motion  over  the  entire  back  a  certain  quantity  of  mercurial  oint- 
ment, generally  from  |-  to  1  of  an  ounce.  The  rubbing  is  kept  up 
for  about  twenty  minutes.  A  gauze  shirt  is  put  immediately  in 
contact  with  the  skin,  and  at  the  end  of  twenty  or  twenty-two 
hours  the  same  process  is  repeated.  Inunction  is  very  valuable 
where  rapid  and  thorough  mercurialization  is  desired. 

Fumigation  may  be  had  at  any  of  the  Turkish-bath  establish- 
ments. It  is  also  used  when  a  prompt  action  of  mercury  is 
desired.  It  is  a  very  good  method  and  unattended  with  any  dis- 
agreeable features,  the  only  objection  being  that  it  is  generally 
impracticable. 

Hypodermic  injections  of  mercury  are  coming  into  more  favor, 
and  their  use  attended  with  more  favorable  results.  The  following 
solution  is  a  favorite  one : 

R.  Hydrarg.  bichlor..  gr.  viij  ; 

Ammon.  muriat.,  gr.  iv; 

Aqua  bullien.,  §ss. — M. 

Abscesses  may  follow  the  puncture. 


TREATMENT.  29 

How  are  the  iodides  administered,  and  when  called  for,  in  the 
treatment  of  syphilis? 
If  the  disease  is  taken  in  hand  early  and  kept  under  a  judicious 
dose  of  mercury,  there  being  no  tertiary  symptoms,  there  is  no  pos- 
itive indication  for  the  use  of  the  iodides  unless  the  early  symptoms 
are  very  severe  and  protracted.  When  both  drugs  are  combined  it 
is  termed  the  "  mixed  treatment."  The  vehicle  of  such  a  mixture 
may  consist  of  a  stomachic  or  bitter  tonic  or  syrup.  When  the 
symptoms  are  of  such  severity  that  it  is  desired  to  obtain  a  rapid 
full  effect,  the  iodide  of  potash  may  be  given  in  a  saturated  solu- 
tion with  water,  1  ounce  of  the  drug  to  1  ounce  of  water.  In  the 
mixed  treatment,  where  the  mild  continuous  effect  of  the  drug  is 
desired,  it  is  generally  given  in  doses  of  from  5  to  10  grains  three 
times  a  day ;  but  where  it  is  desirable  to  obtain  a  rapid  response 
from  its  use  in  the  case  of  destructive  tertiary  lesions,  where  irre- 
parable damage  is  threatened,  there  is  no  limit  to  the  amount  that 
may  be  given :  2  J  ounces  have  been  taken  daily,  and  even  more 
than  this.  Commencing  with  5  or  10  grains,  it  may  be  rapidly  run 
up,  doubling  the  dose  every  day  or  every  other  day.  Given  alone 
and  in  such  large  doses,  the  iodides  seem  to  be  best  borne  if  dis- 
solved in  milk. 

What  are  the  bad  effects  produced  by  the  mercurial  prepara- 
tions ? 

Salivation  and  diarrhoea,  with  griping  pains,  may  be  caused, 
together  with  a  peculiar  mental  condition  which  consists  of  a  gen- 
eral depression  and  nervous  disquietude,  the  patient  being  discon- 
solate and  downcast. 

What  is  the  cause  of  salivation? 

It  may  occur  from  an  idiosyncrasy  with  a  small  dose  or  from 
large  doses  with  no  idiosyncrasy.  A  lack  of  cleanliness  of  the 
mouth  is  apt  to  favor  the  condition. 

What  are  the  symptoms  of  salivation  ? 

The  saliva  overflows,  sometimes  to  a  very  great  extent.  The 
breath  becomes  foetid,  and  there  is  a  metallic  taste  in  the  mouth ; 
the  gums  become  sore  and  may  bleed  ;  the  teeth  ache,  and  pain  is 
caused  by  gentle  pressure  against  them.  The  tongue  swells,  as 
may  also  the  lips  and  teeth  ;  the  lymphatic  glands  in  the  vicinity 
become  enlarged  ;  sometimes  the  teeth  fall  out.  Various  degrees 
of  this  condition  are  met  with.  It  may  be  very  mild  or  appear 
with  all  the  above  symptoms. 


30  SYPHILIS. 

What  is  the  treatment  of  salivation? 

It  is  sometimes  warded  off  by  administering  good-sized  doses  of 
chlorate  of  potash  during  the  course  of  the  bichloride  of  mercury. 
When  it  occurs,  chlorate  of  potash  may  also  be  used  internally  and 
the  mouth  washed  with  a  bland  cleansing  lotion. 

INFANTILE  AND  INHERITED   SYPHILIS. 

In  what  different  ways  may  an  infant  become  syphilitic  ? 

Syphilis  may  be  acquired  by  a  healthy  baby  while  nursing  from 
a  woman  who  has  lesions  around  the  nipple,  or  through  vaccina- 
tion, or  in  any  other  way  which  brings  the  virus  in  contact  with  an 
abraded  surface.  When  the  disease  is  so  acquired  it  is  virtually 
the  same  as  in  the  adult.  An  infant  may  also  become  infected 
in  its  passage  through  the  parturient  canal.  Syphilis  is  inlieyHted 
from  a  mother  who  is  syphilitic,  yet  who  does  not  at  the  time  show 
any  outward  symptoms  of  the  disease.  It  may  also  become  infected 
through  the  mother  at  the  time  of  impregnation  or  during  utero-ges- 
tation  up  to  about  the  seventh  month,  according  to  Diday.  This 
question  is  still  under  discussion. 

When  an  infant  has  inherited  syphilis,  what  is  the  time  of 
appearance  of  symptoms? 

This  is  variable.  A  syphilitic  woman  usually  aborts  if  no  treat- 
ment is  employed,  the  cause  of  which  is  said  to  be  contamination 
of  the  foetus  through  visceral  disease  and  degeneration  of  the  pla- 
centa. Failing  this,  the  child  may  be  born  and  delivered  with  an 
eruption  covering  its  body  and  advanced  syphilis  of  the  different 
organs.  This  is  soon  followed  by  a  fatal  issue.  Often  the  infant 
comes  into  the  world  apparently  healthy,  but  fails  to  continue  so, 
develops  an  eruption  and  a  coryza,  and  loses  weight,  generally 
about  the  third  or  fourth  week,  or  it  may  be  months  before  any 
signs  appear,  but  this  is  uncommon.  More  rarely  it  happens  that 
several  years  elapse  before  symptoms  ensue. 

What  are  the  symptoms  of  inherited  syphilis  ? 

When  the  symptoms  do  not  appear  until  weeks  after  birth,  the 
child  during  this  time  generally  shows  a  failure  in  gaining  weight — 
has  an  unhealthy  and  weazened  appearance.  Generally  the  first  out- 
break is  at  the  junction  of  the  mucous  membranes  with  the  skin  at 
the  different  orifices,  which  reveal  fissures,  excoriations,  mucous 
patches,  and  ulcers  invading  the  lips,  the  inside  of  the  mouth  and 
throat,  and  finally  the  genitals,  buttocks,  groins,  etc.     The  nose 


INFANTILE   AND  INHERITED   SYPHILIS.  31 

runs,  and  later  becomes  stopped  up  from  swelling  of  the  mucous 
membrane.  If  the  disease  continues,  in  bad  cases  the  nasal  carti- 
lages may  become  ulcerated,  and  this  ulceration  continues  so  as  to 
extend  down  the  pharynx  or  destroy  the  bones  of  the  nose  ;  the 
mucous  patches  become  covered  with  scabs  or  form  dark  crusts, 
which  in  turn  may  become  the  seat  of  true  ulceration  in  different 
parts  of  the  body,  especially  around  the  anus.  Mixed  with  the 
scattered  mucus  and  scabby  deposits  there  may  be  a  roseolar  erup- 
tion and  papules.  Pustules  and  bullae  also  occur  in  the  feeble  and 
poorly-nourished  children.  The  eyes  are  not  affected,  except  with 
a  conjunctivitis  in  connection  with  the  coryza.  The  bones,  carti- 
lages, and  joints  suffer  ns  in  the  acquired  form  of  the  disease. 
Some  especial  lesions  of  these  tissues,  which  involve  degeneration 
and  softening  and  syphilitic  outgrowths,  are  described  by  different 
authors.  The  viscera  may  also  be  affected  in  the  inherited  as 
in  the  acquired  form  of  syphilis,  and  it  is  these  lesions  which  make 
the  former  so  commonly  fatal.  There  is  something  in  the  counte- 
nance of  a  child  inheriting  this  disease  which  may  be  termed  syph- 
ilitic. His  skin  is  pallid  and  coarse  ;  he  is  apt  to  have  prominent 
cheek-bones  and  overhanging  forehead,  with  perhaps  sunken  nasal 
bones ;  he  is  generally  unintelligent  and  dwarf-like.  The  perma- 
nent teeth  are  irregular  and  defective,  especially  the  two  middle 
upper  incisors,  which  are  small  and  either  converging  or  diverging  ; 
they  are  poorly  developed,  often  marked  with  ridges  and  furrows  in 
front,  and  their  edges,  which  are  thin  and  irregular  when  cut,  break 
off  centrally,  leaving  a  regularly  shallow  vertical  notch  on  the  lower 
border.  All  syphilitic  children  have  not  necessarily  these  "blight- 
ed "  teeth. 

The  prognosis  of  inherited  syphilis  is  bad,  and  is  generally  pro- 
portionate to  the  date  of  appearance  of  symptoms  and  the  general 
physical  condition  of  the  infant.  Nasal  catarrh  may  be  severe 
enough  to  interfere  with  nursing ;  vomiting  and  diarrhoea,  persist- 
ing, interfere  with  nutrition  and  make  the  prognosis  graver.  When 
a  child  is  born  with  a  general  eruption,  visceral  lesions  are  most  apt 
to  be  present,  and  death  may  be  expected. 

What  is  the  treatment  of  inherited  syphilis? 

Before  birth,  if  the  infant  is  believed  to  be  syphilitic,  treatment 
should  be  commenced  by  putting  the  mother  under  mild  mercurial 
influences.  By  such  means  an  abortion  may  be  averted  and  the 
child  saved  from  an  early  death.     The  methods  of  treating  a  child 


32  CHANCROID. 

with  inherited  syphilis  after  birth  are  by  inunction  or  by  the  use  of 
the  mercury  with  chalk  or  by  solution  of  bichloride  in  water.  The 
manner  suggested  of  applying  the  former  is  to  spread  the  mercu.! 
ointment  upon  the  child's  bellyband  or  upon  bandages  applied  to 
the  anus  or  legs.  The  hydrargyrum  cum  creta  is  used  in  grain 
doses,  repeated  according  to  the  symptoms  and  effect  produced. 
The  bichloride  may  be  used  in  a  weak  solution,  made  so  that  an 
infinitesimal  dose  may  be  given  with  the  food  frequently  or  a  larger 
dose  three  or  four  times  daily.  The  iodides  are  not  generally  well 
borne  by  the  infant  stomach,  but  in  the  tardy  lesions  they  must  be 
resorted  to.  Administered  to  the  mother,  the  iodides  are  eliminated 
with  the  milk,  and  may  be  thus  transmitted  to  the  child.  Local 
treatment  of  excoriations  and  ulcers  requires  cleanliness  and  the 
use  of  some  bland  ointment  or  powder  or  mild  mercurial.  The 
general  hygiene  and  the  nourishment  of  the  child  claim  the  proper 
notice. 

CHANCROID, 

What  is  chancroid? 

The  local  venereal  sore. 

Wherein  does  it  differ  from  chancre  ? 

Chancre  is  a  local  manifestation  of  a  general  disease,  whereas 
chancroid  is  entirely  a  local  malady. 

What  is  the  cause  of  chancroid  ? 

Chancroid  is  always  due  to  the  inoculation  of  pus  derived  from  a 
similar  ulcer. 

Is  chancroid  single  or  multiple  ? 

It  is  multiple.     Its  own  secretions  are  freely  auto-inoculable. 

What  is  the  nature  of  the  discharge  of  chancroid  ?  and  what  are 
its  properties? 

Thick,  richly  purulent,  brownish  or  reddish  yellow,  corrosive. 

How  long  after  exposure  does  chancroid  make  its  appearance? 

Almost  immediately  upon  absorption.  There  is  no  period  of  in- 
cubation, as  in  the  case  of  chancre,  but  it  appears  generally  within 
the  first  two  or  three  days  after  contact.  If  the  virus  be  received 
upon  an  unbroken  surface,  there  is  a  necessary  delay  in  its  appear- 
ance. 


CHANCROID.  33 

What  general  characteristics  does  the  ulcer  itself  possess  ? 

-A  rounded,  sometimes  oval,  margin,  abrupt,  perpendicular  edges, 
v/^ten  everted  and  undermined ;  ulceration  rather  deep  ;  bottom  of 
ulcer  irregular  and  grayish-yellow  in  appearance,  covered  by  a  pul- 
taceous,  adherent  substance  and  flabby  granulations  bordered  by  a 
pink  areola. 

Is  pain  an  accompaniment  of  chancroid  ? 

Yes ;  its  tendency  to  corrode  causes  a  continual  pain,  and  the 
inflammatory  condition  present  renders  it  sensitive  on  manipulation. 

What  is  the  course  of  chancroid  ? 

It  increases  in  size  from  one  to  two  weeks,  preserving  its  charac- 
teristics, when  it  generally  reaches  its  maximum  size.  At  this 
period  it  usually  continues  to  remain  one  size,  undergoing  no 
noticeable  change  until  repair  sets  in. 

How  does  repair  of  the  ulcer  show  itself? 

It  shows  itself  in  a  more  healthy  condition  of  the  discharge,  a 
sloping  of  the  abrupt  edges  of  the  ulcer,  a  more  granular  condition 
of  the  base,  which  gradually  cicatrizes  from  its  edges  toward  the 
centre. 

What  kind  of  a  scar  is  left  by  the  chancroid  ? 

It  varies  with  the  depth  of  the  ulcer.  It  may  be  so  faint  as  to 
eventually  disappear,  or  it  may  remain  as  a  puckered  and  pinched- 
out,  unsightly  scar  of  a  size  proportioned  to  the  previous  ulceration. 

What  are  the  complications  of  chancroid  ? 

Inflammation,  vegetations,  phimosis  and  paraphimosis,  lymphan- 
gitis, erysipelas,  gangrene,  phagedgena,  simple  bubo,  and  virulent 
bubo. 

How  do  vegetations  occur? 

These  warty  growths  may  complicate  chancroid,  as  they  may  any 
other  ulceration  about  the  region  of  the  prepuce  or  anus. 

What  is  the  cause  of  the  inflammation  accompanying  chancroid  ? 

It  may  be  mechanical  from  friction,  erection,  or  irritating  appli- 
cations, encouraged  by  a  lack  of  cleanliness,  debility,  etc. 

What  are  the  concomitants  of  such  inflammation  ? 

Phimosis  and  paraphimosis  are  likely  to  accompany  inflammation 
in  chancroid  where  there  is  a  long  foreskin,  and  possibly  erysipelas, 


34  CHANCROID. 

which  in  debilitated  conditions  tends  to  predispose  to  sloughing  and 
phagedsena. 

Wherein  does  chancroid  in  its  general  appearance  differ  from 
chancre  ? 

In  the  greater  amount  of  its  discharge  and  its  more  purulent 
nature  ;  in  the  irregularity  of  the  ulcer  and  its  undermined  edges  ; 
in  the  pain  which  accompanies  it,  and  in  the  absence  of  all  indu- 
ration. 

What  is  the  treatment  of  chancroid  ? 

The  treatment  is  entirely  local,  as  there  is  no  constitutional  disease 
to  combat  except  that  which  may  exist  from  the  absorption  of  the 
poison  from  the  local  sore. 

What  is  the  first  method  of  treatment  to  consider  ? 

Destruction  of  the  ulcer  by  proper  and  effective  caustics.  v 

What  agents  shall  we  use  to  accomplish  this  end? 

After  applying  to  the  ulcerated  surfaces  a  4  per  cent,  solution  of 
cocaine  to  properly  ansesthetize,  we  may  use  pure  carbolic  acid, 
followed  up  by  fuming  nitric  acid.  If  the  ulcer  or  ulcers  be  at- 
tacked in  their  early  career,  this  may  suffice  to  annihilate  them ; 
but  if  after  a  few  days  the  patient  returns  not  only  with  a  healthy 
healing  sore,  but  also  with  a  partially  unhealthy  ulcerating  surface, 
a  remnant  of  the  chancroid,  by  repeating  this  method  of  cauteriza- 
tion, as  a  rule,  the  ulcer  may  be  entirely  destroyed.  A  recent  in- 
troduction known  as  "  pyrozone  "  (containing  25  per  cent,  peroxide 
of  hydrogen)  is  said  to  be  effectual  as  a  caustic  for  these  ulcers. 

Can  the  virulent  properties  of  chancroid  be  destroyed  and  its 
career  terminated  prematurely  by  other  than  caustic  rem- 
edies ? 

Only  in  mild  cases,  when  strong  solutions  of  bichloride  of  mer- 
cury, as  strong  as  1:500  or  1 :  1000,  constantly  kept  in  contact 
with  the  ulcer,  are  the  best  means  suggested  for  this  purpose. 

What  more  active  mode  of  destruction  have  we  when  the  ulcer 
resists  the  ordinary  means  or  phagedsena  sets  in  ? 
The  use    of   the    actual    cautery   or  the   application   of   strong 
sulphuric  acid  made  into  a  paste  with  willow  charcoal  (Ricord). 
The  pain  accompanying  this  latter  procedure  is  extremely  severe. 

What  is  the  difference  between  syphilitic  and  chancroidal  bubo  ? 

Syphilitic  bubo  has  been  already  mentioned.     Chancroidal  bubo, 


CHANCROID.  35 

instead  of  being  multiple,  is  generally  confined  to  one  gland,  is 
boggy,  extensive,  and  painful,  generally  suppurates,  and  is  not 
freely  movable  under  the  integumentary  tissues. 

What  is  the  difference  between  simple  and  virulent  bubo  ? 

Simple  bubo  is  essentially  the  same  as  inflammatory  glandular 
swelling,  which  may  occur  after  any  local  irritation,  such  as  vacci- 
nation or  an  inflamed  corn.  Virulent  bubo  is  the  result  of  absorp- 
tion of  matter  from  chancroid. 

What  are  the  differences  in  the  characteristics  of  these  two  buboes  ? 

Simple  bubo  may  or  may  not  suppurate.  When  it  does,  the 
causes  of  such  suppuration  are  the  same  as  might  cause  suppura- 
tion in  any  other  portion  of  the  body.  Virulent  bubo  suppurates, 
as  a  rule,  as  it  contains  the  same  substance  by  absorption  which 
the  chancroid  does,  and  its  tendency  is  to  expel  it.  After  suppu- 
ration the  entire  area  involved  by  the  bubo  assumes  the  appearance 
and  characteristics  of  chancroid. 

What  is  the  treatment  of  bubo  of  chancroid? 

If  the  bubo  be  simple,  without  any  tendency  to  suppuration, 
sometimes  external  pressure,  applied  by  means  of  a  shot-bag  or  a 
closely-applied  bandage,  in  conjunction  with  other  local  treatment, 
may  suffice  to  reduce  the  inflammation  ;  but  if  the  bubo  tends  to 
suppuration,  the  only  method  of  treatment  which  can  be  pursued 
is  poulticing  and  incision  of  the  gland  so  soon  as  the  pus  announces 
itself,  at  which  time  the  necrosed  and  broken-down  tissue  may  be 
scraped  away  or  total  extirpation  of  the  gland  be  resorted  to,  which 
may  hasten  recovery. 

Total  extirpation  of  the  gland  is  sometimes  resorted  to  before 
suppuration  shows  itself,  with  the  idea  of  obtaining  primary  union 
of  the  wound.  The  skin  over  the  gland  is  too  apt  to  be  involved, 
and  the  undertaking  is  not  often   successful. 

The  treatment  of  virulent  bubo  after  opening  is  the  same  as  that 
of  the  chancroid  itself. 

What  is  the  differential  diagnosis  between  chancroid  and  chancre  ? 

Chancre    {Primary    Lesion    of  Chancroid       {Local       Venereal 

Syphilid).  Sore). 

Well-marked    period  of  incuba-  No  incubation  appears  soon  after 

tion.  contact. 

More  apt  to  be  single.  Usually  multiple. 


36  VENEEEAL   WARTS. 

Chancre.  Chancroid. 

Indurated  base   (exceptions   oc-  Generally  soft  and  succulent. 

cur). 

Generally    flat ;    even   with    the  Undermined  and  uneven. 

surface  or  protruding. 

Discharge  thin,  serous,  or  sero-  Discharge    thick,    purulent,    or 

purulent.  sanguino-purulent. 

.  VENEREAL  "WARTS. 

What  are  venereal  warts? 

Vegetations  which  appear  upon  the  penis,  which  have  derived 
this  name  from  their  association  with  venery  in  general,  but  which 
are  not  necessarily  referable  to  this  cause. 

What  do  they  consist  of? 

They  are  papillary  outgrowths  which  appear  upon  the  mucous 
membrane  of  the  prepuce  or  glans  penis.  They  are  composed 
largely  of  epithelium,  and  are  generally  highly  vascular. 

What  different  appearances  may  they  present? 

They  may  be  flat  or  pedunculated,  generally  multiple,  but  some- 
times single. 

What  is  the  cause  of  their  existence  ? 

They  are  generally  produced  by  irritation  of  some  kind  in  the 
form  of  fluid,  which  may  be  present  in  the  mere  condition  of 
uncleanliness. 

Where  do  these  warts  generally  appear? 

Their  most  common  seat  is  on  the  mucous  membrane  behind  the 
corona  glandis,  but  they  often  involve  not  only  this  site,  but  also 
the  entire  mucous  membrane  covering  the  prepuce  and  the  glans, 
or  even  within  the  urethra.  They  are  found  also  upon  the  scrotum 
and  frequently  around  the  anus.  In  women  they  may  cover  the 
entire  mucous  membrane  of  the  labia. 

Are  they  accompanied  by  any  discharge  ? 

They  are  generally  moist,  and  when  numerous  are  apt  to  be 
bathed  with  a  serous  and  foetid  secretion. 

Are  these  growths  contagious? 

Under  similar  conditions  in  which  they  seem  to  thrive  there  is  a 
contagious  element  about  them. 


GENITO-UEINARY   DISEASES — VENEREAL.  37 

What  is  the  proper  method  of  treatment  to  pursue  for  these  out- 
growths ? 

In  the  flat  and  non-exuberant  form  local  astringent  applications 
or  powders,  accompanied  by  cleanliness,  may  suffice  to  effect  their 
removal. 

What  applications  are  most  effective? 

Dilute  nitric  acid  in  solution  and  calomel  powder. 

When  the  warts  are  more  numerous  and  extensive,  what  means 
must  he  resorted  to? 
Excision  of  the  growths  and  cauterization   of  their  bases   by 
fuming  nitric  acid. 

What  is  the  best  method  of  accomplishing  this  ? 

The  warts  may  be  nipped  off  by  means  of  a  pair  of  scissors,  and 
their  bases  treated  with  nitric  acid,  or  they  may  be  tied  off  with  fine 
silk,  and  then  the  nitric  acid  used.  A  most  satisfactory  way  is  to 
snare  off  the  warts  slowly  by  means  of  a  small  polypus  snare,  and 
then  resort  to  the  nitric  acid  for  destruction  of  the  pedicle.  The 
advantages  of  this  mode  are  that  it  is  practically  painless  and  free 
from  the  annoying  hemorrhage  that  generally  accompanies  excision 
of  these  growths.  The  slower  the  snare  be  tightened,  the  less  the 
pain  and  less  the  hemorrhage  that  follow. 


GENITO-URINAEY  DISEASES— VENE- 
REAL. 

DISEASES  OF  THE  MALE  URETHRA. 

What  is  the  urethra  ? 

The  urethra  is  a  collapsed  tube  or  channel  leading  from  the 
bladder  to  the  external  meatus. 

What  are  its  functions? 

It  serves  as  an  excretory  duct  for  the  removal  of  the  urine  after 
it  has  accumulated  in  the  urinary  reservoir  or  bladder.  It  serves 
as  a  channel  for  the  egress  of  the  seminal  fluid  during  the  act  of 
sexual  intercourse,  and  also  acts  as  a  genital  organ  in  supplying 
by  means  of  its  surrounding  glands  a  mucous  fluid  which  takes 
part  in  the  composition  of  the  semen. 


38  THE   URETHRA. 

How  long  is  the  male  urethra? 

Eiglit  inches. 

How  is  it  divided  for  description? 

Into  the  pendulous  or  spongy  portion,  or  that  portion  lying 
within  the  pendulous  organ,  about  6  inches  in  length ;  the 
membranous  urethra  between  the  triangular  ligament  and  the 
apex  of  the  prostate,  about  f  of  an  inch  ;  the  prostatic  portion, 
about  IJ  inches,  situated  within  the  prostate  and  terminating  at 
the  neck  of  the  bladder. 

What  is  the  construction  of  the  spongy  portion  of  the  urethra? 
It  is  surrounded  throughout  by  the  erectile  tissue  of  the  corpus 
spongiosum,  or  spongy  body  of  the  penis,  commencing  at  the  mea- 
tus or  external  opening  and  terminating  at  the  bulb,  which  is  the 
enlarged  portion  of  the  corpus  spongiosum  below. 

Where  is  the  triangular  ligament  ?  and  what  are  its  relations  to 
the  urethra? 

The  triangular  ligament  is  a  firm  and  dense  fibrous  fascia  which 
is  pierced  by  the  urethra  just  before  reaching  the  bulb  of  the 
corpus  spongiosum,  and  which  stretches  across  a  space  bounded 
on  either  side  by  the  bony  rami  composed  of  the  ischium  and 
pubis,  and  is  the  boundary-line  between  the  erectile  urethra  and 
the  membranous. 

By  what  is  the  urethra  covered  after  it  loses  its  erectile  proper- 
ties and  becomes  membranous? 

By  voluntary  muscular  tissue,  which  surrounds  it. 

What  is  the  importance  of  the  muscular  covering  of  the  mem- 
branous urethra? 

It  is  often  the  seat  of  spasmodic  stricture,  and  its  contraction 
may  oppose  the  passage  of  the  instrument  into  the  bladder. 

What  action  has  this  muscle? 

It  is  the  so-called  "  cut-ofi"''  muscle,  which  controls  the  act  of 
urination,  by  means  of  which  the  urine  may  be  stopped  during  its 
flow.     Relaxation  allows  an  involuntary  flow. 

What  is  the  natural  condition  of  this  muscle  in  health? 

Its  natural  condition  is  that  of  tension,  the  degree  of  which  may 
become  more  or  less  modified  by  excesses  and  disease.  This  muscle 
also  acts  as  a  valve,  preventing  fluids  injected  through  the  meatus 
from  entering  the  bladder. 


c 


URETHRITIS.  39 


URETHRITIS. 


What  is  inflammation  of  the  urethra  called? 
Urethritis. 

How  is  urethritis  divided? 

Into  specific  and  non-specific  urethritis. 

What  is  non-specific  urethritis? 

Inflammation  afi'ecting  the  urethral  mucous  membrane,  the  result 

of  irritation  from  any  cause. 

What  are  the  most  frequent  causes  of  non-specific  urethritis  as 
it  is  found  in  general  practice? 

Excessive  venery,  self-abuse,  excessive  indulgence  in  alcoholic 
stimulants,  intercourse  with  a  female  during  her  menstrual  epoch, 
or  a  combination  of  any  or  all  of  these  causes.  Thus  it  may  be  seen 
how  often  the  non-specific  or  simple  urethritis  may  be  confounded 
with  and  looked  upon  as  a  case  of  gonorrhoea,  the  history  being 
of  a  suspicious  intercourse  when  possibly  under  the  influence  of 
liquor,  followed  by  the  most  noticeable  and  cardinal  symptom  of 
o-onorrhaa — namely,  a  discharge  of  pus  from  the  urethra. 

Any  irritation  which  might  reach  the  urethra  from  without  by 
means  of  violence,  acids,  and  like  substances  which  may  be  elim- 
inated through  the  urine  in  suflicient  quantities  to  cause  irritation. 

What  are  the  symptoms  of  simple  urethritis? 

A  burning  sensation  during  urination,  a  discharge  of  a  mucous, 
muco-purulent,  or  purulent  nature  according  to  the  grade  of  the 
inflammation,  accompanied  by  painful  erections. 

Has  this  simple  inflammation  generally  any  period  of  incubation  ? 
Xo  ;  it  need  have  none.  It  often  appears  the  day  after  a  sexual 
intercourse,  but  it  is  apt  to  be  produced  by  a  combination  of  causes 
and  the  result  of  continuous  irritation,  the  amount  of  which  may 
not  be  suflicient  to  produce  inflammation  for  several  days  after 
sexual  intercourse,  as  from  a  continuous  indulgence  in  alcoholic 
stimulants,  and  thus  it  may  be  seen  that  an  apparent  period  of 
incubation  will  exist. 

What  is  the  treatment  of  simple  urethritis? 

Often  relief  from  the  exciting  cause  may  be  sufficient  to  termi- 
nate the  trouble,  and  the  disease  will  get  well  itself.     If.  however. 


40  GONORRHOEA. 

medicinal  means  be  required,  the  administration  of  a  saline  diuretic 
in  sufficient  quantity  to  alkalinize  the  urine  should  be  sufficient  to 
produce  the  desired  effect. 

Are  local  measures  of  treatment  sometimes  necessary? 

They  may  be,  and  if  used  a  very  mild  injection  of  sulphate  of 
zinc  or  some  vegetable  astringent  can  be  employed,  but  care  should 
be  taken  that  the  injection  itself  does  not  keep  up  the  disease  by 
continuing  the  irritation. 

What  is  specific  urethritis? 

Specific  urethritis,  from  the  frequency  of  its  occurrence,  has 
received  a  special  name  for  its  distinction — namely,  gonorrhoea — 
and  is  inflammation  of  the  urethral  mucous  membrane  derived 
from  a  source  containing  the  specific  germs  which  produce  this 
disease  ;  in  other  words,  the  same  disease  in  another.  It  is  almost 
invariably  derived  during  sexual  intercourse. 

GONORRHCEA. 

What,  then,  is  the  essential  difference  between  simple  urethritis 
and  gonorrhoea? 

The  existence  of  a  peculiar  micro-organism  or  specific  germ  in 
the  discharge  from  the  urethra  of  the  latter  disease. 

What  is  this  micro-organism  called? 

It  has  been  named  by  Neisser,  who  first  pointed  it  out,  the 
"  gonococcus." 

How  is  this  gonococcus  to  be   distinguished,  and  its   existence 
determined  upon? 

A  small  specimen  of  the  discharge  is  collected  upon  a  cover- 
glass  and  thinly  spread  by  the  pressure  of  another  cover-glass 
over  it,  after  which  the  specimen  is  dried  by  passing  it  once 
through  the  flame  of  an  argand  burner  rapidly.  The  specimen  is 
then  stained  with  a  saturated  solution  of  methyl-violet,  which  is 
accomplished  by  placing  a  drop  of  the  latter  solution  upon  the 
dried  specimen,  and  after  it  is  spread  over  the  entire  area  it  is 
allowed  to  remain  for  a  couple  of  minutes,  after  which  the  speci- 
men is  gently  irrigated  under  a  small  stream  of  water  in  order 
to  remove  the  surplus  coloring  matter.  The  cover-glass  is  then 
mounted  on  a  slide  with  glycerin,  and  by  the  use  of  a  microscope 
of  500  diameters  the  gonococcus,  if  present,  may  be  discovered. 
The  picture  which  presents  itself  in  a  specimen  of  gonorrhoeal  pus 


DIAGNOSIS.  41 

is  the  following :  The  nuclei  of  the  pus-cells  are  very  darkly  stained 
by  the  methyl-violet ;  the  outlines  of  the  cells  are  only  lightly  tinted 
with  the  blue,  while  the  cocci  are  distinctly  and  deeply  marked  out 
in  dark -blue  dots  arranged  around  and  within  the  pus-cells  in  pairs 
and  in  parallel  lines.  Any  other  arrangement  of  dots  means  noth- 
ing, and  may  be  confounded  with  other  cocci  likely  to  be  found  in 
discharges  from  the  urethra  and  elsewhere. 

Has  gonorrhoea  a  period  of  incubation  ?  and  if  so  how  long  after 
exposure  does  the  disease  announce  itself? 

There  is  generally  an  incubation  of  about  five  days,  during  which 

time  there  need  be  no  evidence  of  the  impending  disease. 

What  are  the  first  symptoms  which  appear? 

Generally  the  patient's  attention  is  first  called  to  his  urethra  by 
a  suspicious  burning  sensation,  accompanied  possibly  by  a  small 
amount  of  mucus  or  a  muco-purulent  discharge.  This  discharge 
rapidly  increases  in  quantity  and  the  subjective  symptoms  increase 
in  violence,  so  that  at  the  end  of  the  first  or  the  second  day  in  ordi- 
narily severe  cases  the  discomfort  during  urination  is  very  intense, 
the  discharge  is  thick  and  yellowish-green,  and  erections,  if  they 
occur,  are  extremely  painful. 

What  appearance  does   the  urethra  present  during   this    acute 
stage  ? 

The  lips  of  the  meatus  are  swollen  and  separated,  reddened,  and 
bathed  by  the  thick  and  copious  discharge.  In  uncleanly  persons 
a  balanitis  may  also  present  itself  from  constant  contact,  of  the 
discharge  with  the  surrounding  mucous  membrane. 

What  is  the  duration  of  gonorrhoea? 

In  ordinary  cases  it  lasts  from  three  to  six  weeks,  but  the  dis- 
charge may  continue  long  after  this. 

What  is  the  course  of  a  gonorrhoeal  inflammation? 

The  urethral  inflammation  commences  at  the  meatus  and  travels 
slowly  backward  ;  the  intensity  of  the  symptoms  generally  increases 
more  or  less  during  the  first  week,  and  then  for  a  time  remains  sta- 
tionary, after  which  a  chronic  period  is  attained,  the  duration  of 
which  is  lessened  or  increased  according  to  the  treatment  pursued 
and  the  care  the  patient  takes  of  himself. 

What  is  this  chronic  stage  termed  when  lasting  an  undue  length 
of  time  ? 

Gleet. 


42  GONOBRHCEA. 

Is  gleet  a  symptom  or  a  disease? 

Grleet  is  practically  a  symptom,  and  is  dependent  upon  various 
causes  during  the  last  stage  of  a  gonorrhoea,  such  as  neglect  of 
treatment  or  persistent  treatment  without  reason,  or  excesses  of 
various  kinds  which  would  be  mentioned  as  causes  for  a  simple 
urethritis,  or  it  is  often  accounted  for  by  a  more  serious  condition, 
the  result  of  a  gonorrhoea — namely,  structural  obstruction  of  the 
canal  or  "  strictura  urethrae.'^ 

TREATMENT  OF  GONORRHCEA. 
Can  gonorrhoea  be  aborted  by  any  means? 

Certain  methods  of  treatment  are  resorted  to  with  this  idea  in 
view,  and  it  is  claimed,  with  a  practical  showing  of  cases,  that  this 
can  be  accomplished. 

What  are  the  means  used  to  accomplish  this  end? 

Nitrate  of  silver  and  chloride  of  zinc,  which  were  formerly  used, 
attained  a  reputation,  but  are  now  no  longer  relied  upon.  It  is 
probable  that  acute  outbursts  of  a  chronic  trouble,  which  so  often 
occur,  were  frequently  relieved  by  these  drugs,  and  as  this  condi- 
tion has  so  often  been  confounded  with  fresh  attacks  of  gonor- 
rhoea, their  reputation  no  doubt  was  derived  in  this  way. 

What  are  the  means  at  the  present  day  by  which  gonorrhoea  is 
claimed  to  be  aborted  or  the  course  of  the  disease  substan- 
tially curtailed  within  the  minimum  time  that  the  disease 
usually  runs? 

By  means  of  the  free  irrigation  of  the  urethra  with  solutions 
of  bichloride  of  mercury,  ranging  in  strength  from  1 :  20,000  to 
1 :  30,000. 

Is  there  any  limit  to  the  period  of  the  disease  during  which  this 
treatment  can  be  resorted  to  with  any  efficacy? 

Statistics  show  that  it  is  most  successful  and  most  effective  dur- 
ing the  earliest  stages  of  the  disease.  Indeed,  it  may  be  said  that 
to  be  effective  it  should  be  resorted  to  within  the  first  twenty-four 
hours  of  its  appearance. 

How  can  this  treatment  be  carried  out? 

Either  by  the  physician  or  by  the  patient  himself.  An  ordinary 
fountain  syringe  can  be  used,  with  a  small  nozzle  on  the  end  of  the 
tube,  and  the  fluid  allowed  to  flow  through  the  urethra  as  far  as  it 
will  go,  after  which  it  will  pass  out  alongside  of  the  canula,  suf- 


TREATMENT. 


43 


ficient  space  being  left  between  it  and  the  bottom  of  the  meatus. 
Different  attachments  have  been  devised  for  the  fountain  or  other 
syringes  to  facilitate  an  urethral  irrigation,  the  principal  ones  of 
which  are  depicted  in  the  accompanying  illustrations. 


Fig.  1. 


Firi.  2. 


Nozzles. 


No.  1  allows  the  fluid  to  pass  out  between  the  canula  and  the 
bottom  of  the  urethra.      In   No.   2,  however,  there  is   a   second 
opening  running  through  an  extra  arm,  which  obviates  the  neces- 
sity of  allowing  any  space   for  the  passing 
out  of  the  irrigating  fluid.  Fig.  3. 


How  is  a  patient  enabled  to  irrigate  him- 
self? 

This  may  best  be  accomplished  by  a  foun- 
tain syringe  with  attachment  No.  2,  the  tri- 
angular-shaped affair,  or  by  means  of  the  so- 
called  "  Universal  Injector  "  shown  in  Fig.  3, 
which  consists  simply  of  a  soft-rubber  bulb 
possessing  a  properly  pointed  nozzle,  which 
when  used  is  introduced  as  far  as  possible 
into  the  meatus,  the  urethra  then  being  dis- 
tended by  the  irrigating  fluid,  and  the  nozzle 
then  withdrawn  enough  to  allow  its  escape. 
This  process  is  continued  until  the  contents 
exhausted 


Universal  Injector. 


of  the  injector   are 
which  is  then  refilled  as  many  times   as  required  to 


44  aOKORRHCEA. 

exhaust  the  amount  of  fluid  used  for  each  irrigation.  This  latter 
method  is  the  simplest  for  the  patient's  own  use,  together  with  a 
prescription  for  1  grain  of  bichloride  of  mercury,  to  be  divided  into 
eight  powders,  and  each  powder  to  be  added  to  a  tumbler  of  hot 
water,  and  the  entire  contents  used  in  the  manner  set  down.  The 
use  of  hot  water  is  especially  advised  for  these  solutions,  as  it 
assists  in  allaying  the  inflammation. 

What  are  the  advantages  of  this  method  of  treatment  ? 

If  resorted  to  early  enough  in  the  career  of  the  disease,  it  often 
substantially  limits  its  career,  and  may  actually  abort  it  (?).  It 
does  not  produce  too  great  irritation  or  endanger  stricture,  and 
unless  the  solution  be  too  strong  never  produces  great  irritation. 

How  much  may  this  method  of  treatment  diminish  the  career  of 
the  disease? 

Various  claims  are  advanced  for  it.  In  a  general  way  it  prob- 
ably may  be  said  that  the  sooner  it  is  resorted  to  the  more  effective 
is  the  result.  That  the  career  of  the  disease  is  shortened  by  it,  and 
that  it  is  sometimes  cured  early  in  the  second  week,  is  the  most 
that  can  be  said  of  it.  This  is  probably  not  an  extravagant  claim : 
others  pretend  to  even  better  results. 

If  this  means  of  treatment  is  not  attended  with  success  or  is  not 
pursued,  what  is  the  methodic  treatment  of  gonorrhoea  ? 

This  treatment  is  largely  symptomatic,  commencing  from  the 
start,  when  the  inflammation  is  acute  and  accompanied  by  dis- 
tressing symptoms,  which  it  aims  to  relieve. 

"What  drugs  in  the  early  period  can  be  resorted  to  with  good 
effect? 

If  the  inflammation  be  very  acute,  the  urination  very  painful, 
and  the  parts  much  swollen,  the  administration  of  ^^  of  a  grain 
of  tartar  emetic  and  1  grain  of  nitrate  of  potash  every  hour  for 
four  to  six  doses  may  produce  a  beneficial  effect.  A  saline  diuretic 
should  be  given,  as  in  simple  urethritis,  in  sufficient  quantity  to 
render  the  urine  alkaline.  Many  resort  to  no  other  means  but 
these  during  the  first  few  days  until  the  more  acute  symptoms 
have  subsided. 

What  other  internal  treatment  has  received  reputation  in  this 
disease  ? 

The  administration  of  balsam  of  copaiba  and  the  oil  of  sandal- 
wood, which  seem  to  have  an  especially  soothing  effect  upon  the 


GONORRHCEA.  45 

mucous  membrane  of  the  genito-urinary  tract,  is  resorted  to  dur- 
ing the  first  stage,  either  alone  or  in  the  combination  known  as 
Lafayette's  mixture.  These  medicines  are  increased  up  to  the  full 
tolerance  of  the  stomach,  and  then  held  at  the  maximum  dose  dur- 
ing the  stationary  period  of  the  disease.  If  the  balsam  of  copaiba 
is  used  and  has  not  already  been  combined  with  cubebs,  the  latter 
can  be  efiPectively  used  at  this  time,  and  either  these  or  the  sandal- 
wood oil  continually  pushed. 

"What  injections  should  be  used  during  the  attack  of  gonorrhoea  ? 

In  any  case  during  the  more  acute  stage,  whether  it  be  early  or 
late,  it  is  well  to  commence  with  the  bichloride  irrigations,  and 
even  if  not  pursued  in  the  same  manner  as  laid  down  for  the  ear- 
liest treatment  of  the  disease,  the  irrigation  of  the  urethra  once  a 
day  or  once  in  two  days  with  bichloride  solution  often  produces  a 
desirable  efiect. 

In  regard  to  the  time  of  commencing  other  injections,  while  it 
is  claimed  by  some  that  it  is  best  to  wait  until  the  departure  of  all 
acute  symptoms,  yet  often  if  the  injections  used  be  mild  enough 
they  will  produce  a  satisfactory  effect  even  during  the  very  acute 
stage.  Sulphate  of  zinc,  ^  or  -|-  grain  to  the  ounce  of  diluted  lead- 
water,  is  a  favorite  injection,  and  probably  the  best  to  be  used  in 
the  earlier  stages  of  the  disease.  This  may  be  increased  in  strength 
and  run  up  to  about  8  grains  to  the  ounce. 

After  treatment  has  been  pursued  for  a  certain  length  of  time  dur- 
ing an  ordinary  case  of  gonorrhoea,  is  it  sometimes  well  to  dis- 
continue ? 

At  times  a  long  and  tiresome  chronic  stage  may  be  avoided  by 
the  discontinuance  of  all  treatment,  which  may  be  at  the  bottom 
of  keeping  up  a  slight  and  continual  discharge. 

If  the  disease  lapses  into  a  chronic  stage,  in  spite  of  treatment, 
to  the  extent  of  acquiring  the  title  of  "  gleet,"  what  methods 
of  treatment  should  be  resorted  to? 

When  the  sole  remnant  of  the  disease  is  a  persistent  mucous  or 
muco-purulent  discharge  which  apparently  resists  all  the  ordinary 
methods  of  treatment,  invasion  of  the  deep  urethra  may  be  ex- 
pected, which  is  unreached  by  the  injections  in  the  hands  of  the 
patient,  being  met  at  the  triangular  ligament  by  the  cut-off  muscle. 
In  such  cases  the  systematic  passage  about  once  in  five  days  of 
a  full-sized  steel  instrument  into  the  bladder,  after  a  number  of 
introductions,  may  suffice  to  terminate  the  career  of  the  gleet. 


46  GONORRHCEA. 

What  other  methods  of  treatment  have  we  for  these  uncompli- 
cated cases  of  chronic  urethritis  ? 

Means  which  will  enable  us  to  bring  our  medication  directly  in 
contact  with  the  affected  area. 

How  can  this  be  accomplished? 

By  the  use  of  a  syringe  so  constructed  that  it  can  be  introduced 
from  without  through  the  anterior  urethra  ,and  beyond  the  grasp 
of  the  cut-off  muscle,  and  an  instrument  devised  for  this  purpose 
is  the  Keyes'  deep  urethral  syringe,  shown  in  the  accompanying 
illustration,  improved  and  modified  from   Ultzman's.     It  is  given 

Fig.  4. 


Keyes'  Deep  Urethral  Syringe. 

the  curve  and  shape  of  an  ordinary  steel  urethral  sound  of  a  size 
corresponding  to  about  a  No.  8  of  the  English  scale,  the  barrel  of 
which  is  graduated  so  that  the  exact  quantity  of  fluid  introduced 
can  be  determined. 

What  applications  can  be  used,  and  have  given  the  best  results 
with  this  instrument? 

Sulphate  of  thallin,  nitrate  of  silver,  sulphate  of  copper,  and 
glycerite  of  tannin,  each  of  which  seems  to  have  its  special  adap- 
tation in  different  cases,  yielding  different  degrees  of  irritation 
and  astringency.  While  some  cases  yield  to  the  use  of  one,  in 
others  the  same  may  fail,  and  relief  may  only  be  had  by  resort  to  an- 
other. In  general  it  may  be  said  about  these  injections,  that  for 
the  more  chronic  and  unruly  cases  the  sulphate  of  copper  or  nitrate 
of  silver  is  more  applicable,  and  the  sulphate  of  thallin  in  the 
milder  cases.  The  sulphate  of  thallin  may  be  used  in  solutions  of 
2  or  3  per  cent.,  introducing  at  each  sitting  the  full  contents  of  the 
syringe,  or  about  20  minims,  and  running  the  strength  up  to  a  satu- 
rated solution,  12  per  cent.  The  nitrate  of  silver  may  be  used  in 
solutions  of  various  strengths.  Some  seem  to  tolerate  it  well,  while 
others  are  easily  upset  by  it.     It  is  well  to  start  with  a  mild  solu- 


CAUSATION    AND   DIAGNOSIS.  47 

tion  of  about  a  grain  to  the  ounce,  which  can  be  run  up  according 
to  the  chronicity  of  the  case,  the  tolerance  of  the  patient,  and  the 
result  of  the  injection. 

Sulphate  of  copper  is  astringent,  more  irritating  than  thallin  and 
less  so  than  nitrate  of  silver.  It  may  be  prepared  in  a  10  per  cent, 
solution  in  glycerin  diluted  with  water  to  the  desired  strength, 
which  should  be  at  the  start  1  grain  to  the  ounce,  and  subsequently 
run  up  to  full  strength,  increasing  the  intervals  with  the  strength 
of  the  injections.  Glycerite  of  tannin  is  decidedly  astringent  and 
less  irritating.  It  should  be  employed  in  solutions  reduced  75,  50, 
and  25  times  its  full  strength  with  water. 

What  is  to  guide  us  in  the  choice  of  these  applications  ? 

The  conditions  upon  which  the  gleety  discharge  depends  and  is 
kept  up,  and  the  idiosyncrasies  of  the  patient. 

What  are  the  different  conditions  which  may  be  the  causes  of 
such  a  gleet? 

They  are  congested  and  inflamed  patches,  chronic  cowperitis,  in- 
flammation of  the  seminal  vesicles,  enlargement  of  the  prostate 
from  acute  or  chronic  inflammation  or  chronic  hypertrophy,  tuber- 
cular disease,  mucous  patches,  and  stricture  of  the  urethra. 

What' is  the  most  common  cause  of  keeping  up  a  urethral  dis- 
charge ? 

Stricture,  and  what  may  be  said  to  be  the  next  in  frequency  of 
the  causes  of  this  disorder — probably  altered  patches  of  the  mucous 
membrane  with  or  without  granulations. 

Is  there  any  other  element  which  is  important  as  a  cause  of  a 
long  chronic  discharge  from  the  urethra? 

Yes  ;  a  neurotic  element  seems  in  many  cases  to  be  if  not  the 
most  potent  cause,  certainly  a  very  important  one  to  consider  and 
act  upon. 

What  instrument  have  we  for  diagnosing  the  conditions  of  the 
urethral  mucous  membrane? 

The  endoscope. 

What  can  be  accomplished  by  its  use  ? 

A  careful  exploration  of  the  entire  mucous  surface  can  be  made, 
and  a  comparison  of  the  appearance  and  texture  of  difterent  por- 
tions can  be  accomplished. 


48  GONORRHCEA. 

Is  its  use  essential  in  these  cases? 

By  some  it  is  thought  to  be  almost  indispensable,  but  by  others 
it  is  believed  not  to  be  essential  for  the  rational  treatment  or  care 
of  this  disease,  nor  to  be  able  to  accomplish  or  determine  much 
more  than  could  be  detected  by  the  touch  with  proper  instruments. 
This  much  must  certainly  be  said :  that  if  the  neurotic  element 
enters  into  the  causation  of  a  very  large  number  of  cases,  as  it 
probably  does,  the  more  elaborate  the  means  which  are  resorted  to 
in  endeavoring  to  relieve  this  disorder,  the  more  appalling  will  it 
appear  to  the  susceptible  patient  and  the  more  difficult  to  overcome 
the  neurotic  condition.  In  other  words,  in  such  cases  the  simpler 
the  means  and  the  less  time  made  over  them  the  more  effective  the 
result. 

In  the  use  of  the  endoscope  what  topical  applications  are  sug- 
gested ? 

Iodine,  sulphate  of  copper,  thallin,  and  carbolic  acid,  and  nitrate 
of  silver  in  solution  of  from  2  grains  to  an  ounce  up  to  a  satu- 
rated solution,  applied  by  means  of  cotton  twisted  on  the  end  of  a 
probe.  This  latter  is  most  suitable  where  granulations  are  present. 
Through  the  endoscope  the  healthy  mucous  membrane  presents  a 
rather  pale,  pink  color,  while  the  congested  spots  are  bright  red  and 
may  be  covered  by  granulations. 

How  long  is  the  duration  of  this  chronic  condition  of  urethral  dis- 
charge or  gleet? 

It  may  last  a  fortnight  or  six  weeks  after  the  decline  of  the  acute 
stage,  and  spontaneously  disappear  or  readily  submit  to  the  ordi- 
nary means  of  treatment.  It  may,  on  the  other  hand,  continue 
months,  with  no  other  complications  than  patches  of  urethral  con- 
gestion kept  up  by  irritating  urine  and  irregular  excesses. 

What  will  the  urine  show  in  such  cases? 

When  passed  into  a  clean  conical  glass  and  held  up  to  the  light, 
one  or  more  fine  filaments  or  shreds  may  be  seen  floating  or  swim- 
ming in  the  urine. 

If  examined  by  the  microscope,  what  will  these  shreds  present  ? 

They  will  be  found  to  consist  of  pus-corpuscles,  free  and  in 
patches,  which  amount  to  a  scab  peeled  off  from  the  urethra. 
These  shreds  are  always  found  in  cases  of  forming  stricture. 


SEQUELS.  49 

What  other  sequelae  of  gonorrhoea  are  sometimes  met  with  after 
the  discharge  has  apparently  nearly  ceased  or  is  very  slight  ? 
Constant  pain  of  varying  degree  in  passing  water,  which  may  be 
the  only  symptom  and  may  last  almost  indefinitely,  or  the  pain  may 
be  confined  to  erections  and  ejaculations. 

To  what  may  these  disturbances  be  attributed? 

A  neurotic  condition  of  the  prostatic  urethra.  Sometimes  ure- 
thral neuralgia  is  present,  or  pains  which  are  not  associated  with 
any  of  the  functions  of  the  urethra. 

How  are  these  neurotic  conditions  treated? 

Sometimes  the  use  of  steel  sounds  may  be  effective,  or  the  cold 
sound,  which  consists  of  running  cold  water  through  a  closed  tube 
which  has  two  arms  at  the  end,  one  for  the  entrance  and  one  for 
the  exit  of  the  cold  water,  or  the  application  of  electricity.  Where 
none  of  these  meet  with  success,  discontinuance  of  all  treatment 
is  recommended,  and,  if  possible,  proper  physiological  exercise  of 
the  organ — namely,  by  the  marriage  relation — after  a  careful  ex- 
amination has  been  made  to  eliminate  stricture,  and  to  establish 
positively  the  absence  of  any  gonococci  and  the  deep  urethral  con- 
gestion. 

Do  these  chronic  conditions  of  urethral  inflammation  ever  have 
acute  outbursts? 

Yes  ;  at  such  times  they  resemble  closely  a  fresh  attack  of  gon- 
orrhoea, and  are  often  misleading  to  those  who  do  not  closely  inquire 
into  their  history  or  determine  the  presence  or  absence  of  the  spe- 
cific organism. 

What  are  the  causes  of  these  acute  outbursts  from  chronic  con- 
ditions ? 

Venereal  excesses,  indulgence  in  alcoholic  stimulants,  sometimes 
undue  muscular  exercise,  and  any  of  the  causes  which  might  under 
ordinary  conditions  produce  an  acute  urethritis.^ 

^  In  ray  examination  of  these  cases  of  urethritis  at  the  Demilt  Dispensary 
for  the  presence  of  gonococci  1  have  found  a  large  majority  of  cases  to  be 
acute  outbinsts  of  chronic  conditions ;  and  the  number  has  been  so  large  that 
I  take  it  to  be  a  good  rule  that  if  an  answer  to  the  question  as  to  the  number 
of  attacks  of  gonorrhoea  be  three  or  more,  the  case  in  hand  can  confidently  be 
named  an  acute  outbreak  on  top  of  an  old  attack  which  may  occur  during 
the  course. 

4— G-U. 


50  GONORRHCEA. 

What  are  the  complications  of  gonorrhoea  ? 

Folliculitis,  cowperitis,  severe  chordee,  inguinal  adenitis,  lymphan- 
gitis, gonorrhoeal  rheumatism,  gonorrhoeal  conjunctivitis,  epididymi- 
tis, cystitis. 

What  is  folliculitis  ? 

Folliculitis  occurs  during  the  acute  stage  of  a  gonorrhoea,  distin- 
tinguished  by  one  or  two  hard  lumps  on  the  floor  of  the  urethra, 
and  consists  of  cysts  which  are  formed  by  the  openings  of  the  lacunae 
Morgagni  becoming  occluded,  the  secretion  thus  continuing  to  form, 
and  thus  producing  this  condition.  They  are  accompanied  by  pain, 
and  continue  stationary  for  a  certain  period,  after  which  they  may 
soften  externally,  open,  and  leave  a  fistulous  track. 

What  are  Cowper's  glands? 

Round  glandular  bodies  situated  behind  the  bulb  of  the  urethra, 
having  ducts  which  open  on  its  floor,  through  which  they  contribute 
to  the  fluid  substance  of  the  semen. 

What  is  cowperitis  ? 

Inflammation  of  Cowper's  glands  of  the  urethra.  It  rarely  occurs 
except  as  a  complication  of  urethritis,  and  generally  before  the  third 
or  fourth  week  of  the  gonorrhoea. 

What  are  the  symptoms  ? 

Pain  and  tension  in  the  region  of  the  perineum  around  the  bulb, 
increased  by  pressure  and  friction  of  any  kind.  Examination  reveals 
a  small  ovoid  tumor  which  resembles  somewhat  in  feeling  the  bulb 
of  the  urethra.  Early  in  its  career  cowperitis  involves  the  sur- 
rounding tissues,  after  which  the  detection  of  a  well-defined  tumor 
is  impossible,  and  the  after-occurring  symptoms  resemble  perineal 
abscess.     It  may  undergo  resolution  or  go  on  to  suppuration. 

What  is  the  treatment  of  this  affection  ? 

Early  in  the  disease  the  application  of  leeches,  rest,  and  any 
means  to  allay  inflammation  should  be  resorted  to.  If,  in  spite  of 
treatment,  suppuration  becomes  inevitable,  poultices  should  be 
applied  and  an  early  incision  resorted  to. 

What  is  chordee? 

Chordee  is  a  peri-urethritis,  or  extension  of  the  inflammation  into 
the  tissues  surrounding  the  urethra. 


GONORRHCEAL   RHEUMATISM.  51 

How  does  it  announce  itself? 

Excessive  pain  is  felt  during  erection,  most  frequently  at  night 
and  toward  morning  :  a  great  deal  of  the  pain  is  felt  in  the  stretch- 
ing of  the  erectile  tissue.  On  account  of  the  inflammation  attack- 
ing the  corpus  spongiosum,  a  certain  amount  of  plastic  exudation 
surrounds  the  urethra.  During  erection  of  the  corpora  cavernosa 
the  urethra  is  not  allowed  to  distend  to  its  full  length,  and  conse- 
quently a  characteristic  downward  curve  of  the  penis  is  produced. 
This  serves  to  aggravate  the  pain. 

What  may  be  the  result  of  the  so-called  "  breaking  the  chordee," 
as  practised  by  those  who  think  it  may  relieve  their  suffer- 
ing? 

Urethral  hemorrhage  is  caused,  and  possibly  may  be  the  start- 
ing-point of  organic  stricture. 

What  is  the  treatment  for  chordee? 

Preventive  measures  may  be  adopted  in  the  use  of  such  seda- 
tives as  bromide,  chloral,  and  opium.  It  is  well  also  to  avoid 
lying  on  the  back,  as  toward  early  morning,  when  the  bladder  is 
full,  this  position  seems  to  favor  erection.  When  the  chordee  is 
present  the  application  of  cold  in  the  shape  of  ice  or  water  may 
help  to  reduce  the  severe  tension. 

When  inflammation  and  enlargement  of  the  inguinal  glands  accom- 
pany gonorrhoea,  are  they  apt  to  be  mild  or  severe  ? 

They  are  generally  of  a  mild  type  and  suppuration  exceptional, 
except  in  unhealthy  subjects. 

What  is  the  nature  and  character  of  the  lymphangitis  accompany- 
ing gonorrhoea? 

It  is  similar  to  that  complicating  chancroid,  distinguished  by 
knotty  cords  under  the  skin. 

What  is  the  treatment? 
Rest  and  soothing  lotions. 

GONORRHCEAL  RHEUMATISM. 

Is  gonorrhoeal  rheumatism  a  distinct  variety  of  rheumatism  ?  and 
if  so,  why  ? 

Yes ;  individuals  who  are  not  subject  to  rheumatic  attacks 
often  have  a  form  of  rheumatism  with  gonorrhoea,  and  none  of 


52  GONORRHCEA. 

the   ordinary   causes   of   rheumatism    seem   ever  to  produce  this 
special  variety. 

Has  it  any  relation  to  stoppage  of  the  discharge  or  neglect  in 
treatment  ? 
Apparently  not,  and  it  does  not  seem  to  be  the  result  of  cold. 
A  person  once  aifected  with  gonorrhoeal  rheumatism  seems  always 
to  suifer  a  return  of  the  complaint  with  recurring  attacks  of  the 
disease. 

How  soon  does  gonorrhoeal  rheumatism  follow  the  appearance  of 
gonorrhoea  ? 
It  is  variable — generally  appearing  during  the  first  week  or  ten 
days,  but   may  appear   later,   rarely  during  the    second  or   third 
month. 

Where  is  the  seat  of  gonorrhoeal  rheumatism  ? 

This  is  also  variable.  The  joints  are  most  frequently  attacked; 
often  the  synovial  sheaths,  tendons,  and  muscles,  and  sometimes 
the  bursas  and  nerves.  The  larger  joints  are  more  frequently 
affected,  and  the  disease  is  rarely  confined  to  one  joint. 

What  different,  forms  of  gonorrhoeal  rheumatism  are  met  with  ? 

(1)  Hydrarthrosis,  generally  seated  in  the  knee,  and  sometimes 
the  ankle  or  elbow.  The  effusion  is  generally  very  great ;  the 
pain  is  but  slight,  and  is  increased  during  exercise.  This  is  rather 
a  latent  form  of  the  disease,  and  is  apt  to  disappear  slowly. 

(2)  The  second  form  which  is  described  is  more  like  the  ordi- 
nary rheumatism,  but  more  moderate.  Constitutional  symptoms 
may  accompany  it,  such  as  fever,  etc.,  which  subside  after  a  few 
days.  It  is  apt  to  affect  more  than  one  joint.  The  concentrated 
condition  of  the  urine  found  in  ordinary  rheumatism  does  not  seem 
to  accompany  gonorrhoeal  rheumatism.  Resolution  is  apt  to  be 
very  slight,  and  articular  pains  or  persistent  stiffness  may  be  left 
behind.  Hydrarthrosis  sometimes  persists  after  all  other  symp- 
toms have  subsided. 

(3)  The  third  form  is  where  there  are  pains  in  the  joints,  which 
do  not  seem  to  have  disturbed  functions.  The  pain  may  be  the 
only  symptom,  and  may  strongly  resist  all  treatment,  and  finally 
after  it  has  disappeared  is  apt  to  return  with  the  urethral  dis- 
charge. 


GONORRHCEAL    RPIEUMATISM.  53 

How  are  the  synovial  sheaths  of  tendons  affected  ? 

They  show  rather  intense  swelling  externally  along  their  course, 
and  redness  of  the  skin  ;  sometimes  very  severe  pain,  which  is 
increased  on  pressure.     Resolution  from  this  condition  is  gradual. 

How  do  the  bursse  suffer? 

They  also  are  in  a  condition  of  effusion,  the  tension  of  which 
causes  very  acute  and  severe  pain. 

What  bursae  are  most  liable  to  be  attacked? 

The  one  situated  between  the  tendo  Achillis  and  the  os  calcis, 
and  that  sometimes  found  beneath  the  tuberosity  of  this  bone. 

What  is  the  differential  diagnosis  between  general  rheumatism  and 
gonorrhoeal  ? 

Gonorrhoeal  rheumatism  is  accompanied  by  urethral  inflamma- 
tion, and  has  not  as  one  of  its  causes  cold  or  exposure.  Simple 
rheumatism  comes  from  cold  and  hereditary  tendency.  Gonor- 
rhoeal rheumatism  is  conspicuously  infrequent  in  women ;  not  so 
simple  rheumatism.  Gonorrhoeal  rheumatism  has  not  so  much  of 
the  febrile  character  as  simple  rheumatism.  Simple  rheumatism 
is  more  general  and  the  symptoms  more  severe.  Sweating  is  one 
of  the  striking  symptoms  of  simple  rheumatism,  while  it  is  not 
present  in  gonorrhoeal.  Cardiac  complications  are  frequent  with 
the  simple,  and  uncommon  in  the  gonorrhoeal. 

Does  the  treatment  useful  for  ordinary  cases  of  rheumatism  seem 
to  be  efficacious  in  the  gonorrhoeal  form? 

No ;  such  drugs  as  salicylic  acid  and  iodide  of  potash  and  col- 
chicum  do  not  seem  to  produce  the  same  effect  as  in  the  simple 
form. 

What  treatment  should,  then,  be  pursued  in  gonorrhoeal  rheuma- 
tism? 

The  local  treatment  is  very  important.  Rest  is  essential,  and 
during  the  acute  stage  leeches,  hot  fomentations,  and  the  like  to 
allay  the  inflammatory  symptoms,  and  rational  measures  generally 
for  this  purpose.  In  the  chronic  stage  counter-irritation,  massage, 
and  douching  are  the  measures  to  be  pursued.  In  the  most  aggra- 
vated form  of  gonorrhoeal  arthritis,  where  the  joint  becomes  thor- 
oughly disorganized  and  firm  fibrous  ankylosis  takes  place  in  a 
malposition,  excision  of  the  joint  is  called  for. 


54  GONOERHCEA. 

GONORRHCEAL  OPHTHALMIA. 

What  is  gonorrhoea!  ophthalmia? 

It  is  the  resulting  ocular  trouble  which  accompanies  and  is 
caused  by  gonorrhoea.  It  may  appear  as  either  of  two  kinds — 
namely,  rheumatoid  gonorrhoea!  ophthalmia  and  simple  gonorrhoeal 
ophthalmia. 

Describe  the  rheumatoid  kind. 

It  is  nearly  always  accompanied  by  other  rheumatic  com- 
plications, but  not  necessarily  so.  It  has  no  connection  with  con- 
tagion, and  affects  the  conjunctiva,  the  iris,  and  the  membrane  of 
Descemet. 

What  is  the  second  kind  of  ocular  complication  in  gonorrhcea  ? 

It  is  the  most  common  affection  of  the  eye  accompanying  gonor- 
rhoea. It  is  more  to  be  feared,  as  it  always  results  from  contagion 
or  contact  of  the  urethral  discharge  with  the  conjunctival  mucous 
membrane. 

What  are  the  symptoms  of  the  rheumatic  form  ? 

There  is  a  smoky  appearance  of  the  fluids  in  the  anterior  cham- 
ber;  moderate  congestion  of  the  conjunctiva;  the  sight  is  some- 
what clouded ;  the  pain  is  not  apt  to  be  present,  and  generally  the 
iris  is   unattacked. 

What  is  the  duration  of  this  form  ? 

The  duration  is  variable.  It  may  last  several  weeks  or  only  a 
few  days.  It  generally  runs  a  rapid  course,  and  relapse  is  not  in- 
frequent. No  serious  damage  to  the  eye  is  done,  except  sometimes 
in  cases  where  the  iris  has  been  attacked. 

What  is  the  treatment? 

The  treatment  is  mainly  rest  and  the  use  of  soothing  lotions. 
All  other  measures  are  without  avail,  except  where  there  is  iritis, 
when  atropine  may  be  used,  or  where  the  pains  are  very  severe 
anodynes  may  be  administered. 

What  is  the  cause  of  gonorrhoeal  conjunctivitis  proper  ? 

Contact  of  the  urethral  discharge  with  the  eye  of  the  patient 
or  that  of  another,  or  of  a  secretion  from  a  similar  inflammation 
from  a  sponge  or  other  instrument  brought  in  contact  with  the 
disease  during  treatment. 


GONORRHCEAL    OPHTHALMIA.  55 

What  are  the  symptoms? 

The  symptoms  are  those  of  purulent  conjunctivitis,  but  are  in- 
tensified in  the  rapidity  with  which  they  appear  and  become 
intensely  severe,  doing  damage  within  a  few  days,  and  may  possi- 
bly irretrievably  afi'ect  the  sight  within  this  time  or  even  less. 

What  takes  place  after  infection  ? 

Almost  immediately  the  vessels  of  the  conjunctiva  become 
engorged  and  the  tissues  succulent  with  serum.  The  eyelids  be- 
come puffy  and  pus  bathes  the  surface  of  the  eyeball  and  .oozes 
over  the  lid.  If  the  inflammation  is  not  rapidly  gotten  under 
control,  ulceration  of  the  cornea  will  soon  ensue,  and  if  perforation 
is  produced,  the  aqueous  humor  escapes  and  hernia  of  the  iris  may 
occur. 

What  are  the  principal  differences  between  these  two  forms  of  gon- 
orrhoeal  complications  ? 

Conjunctivitis  must  come  from  contagion,  and  is  rare,  while  the 
ophthalmia  is  not  contagious,  and,  though  not  common,  is  much 
more  so  than  the  contagious  form.  The  opJithalmia  can  only  affect 
those  suffering  from  gonorrhoea.  As  a  rule,  in  conjunctivitis  one 
eye  only  is  affected,  while  in  the  other  it  is  apt  to  be  both  eyes,  and 
sometimes  passes  from  one  eye  to  the  other.  There  is  no  tendency 
to  relapse  in  conjunctivitis,  while  there  is  in  the  other  form,  which 
is  apt  to  be  coincident  with  gonorrhoeal  rheumatism. 

The  prognosis  of  conjunctivitis  is  very  grave,  and  it  often 
causes  the  loss  of  an  eye ;  it  is  free  from  gravity  in  the  milder 
disease. 

What  are  the  rules  of  treatment  in  conjunctivitis  ? 

Treatment  should  be  resorted  to  immediately ;  delay  is  most 
dangerous.  Measures  should  aim  at  the  cleanliness  of  the  eye, 
the  relief  of  the  tension  caused  by  the  congestion  and  "  chemosis,"' 
and  the  use  of  a  strong  and  effective  cauterant.  The  well  eye 
should  be  carefully  protected.  Strong  purgatives  should  be  at 
once  given  and  a  low  diet  enjoined,  together  with  such  local  means 
as  will  actively  lessen  the  tension,  such  as  bloodletting,  leeching, 
or  cupping,  and  scarifying  the  mucous  membrane.  The  affected 
eye  should  be  shaded  from  the  exertion  of  bearing  the  light.  As 
soon  as  the  pus  begins  to  form,  a  strong  solution  of  nitrate  of  sil- 
ver, of  about  10  or  20  grains  to  the  ounce,  should  be  painted  over 
the  affected  mucous   membrane   and   cold  applications   constantly 


56  GONORRHCEA. 

applied.  Every  few  hours  the  silver  solution  should  be  reapplied. 
The  strength  of  the  solution  should  be  run  up  to  full  strength  or 
the  solid  stick  employed.  When  the  acuteness  of  the  symptoms 
commences  to  subside  milder  astringent  lotions  may  be  used  as 
applications. 

STRICTURE   OF   THE  URETHRA. 

What  is  stricture  of  the  urethra  ? 

Roughly  considered,  it  consists  of  a  narrowing  of  the  canal,  the 
result  of  former  disease  or  injury  or  the  symptom  of  present 
trouble.  The  former  kind  is  called  organic  and  is  permanent ;  the 
latter  is  symptomatic  and  transient. 

What  are  the  causes  of  this  second  class  of  stricture  ? 

Predisposing. — Neurotic  conditions,  hereditary  or  acquired  ;  emo- 
tional, irritable,  morbid,  and  rheumatic  subjects. 

Exciting. — Any  local  irritation  caused  by  a  foreign  body,  reflex 
from  the  rectum  or  direct  from  the  urine,  etc. 

Where  is  the  seat  of  the  contraction  of  spasmodic  stricture  ? 

In  the  unstriped  muscular  fibres  surrounding  the  urethra  at  the 
point  of  irritation.  It  is  commonly  found  at  the  membranous 
urethra  in  the  "  cut-off"  muscle. 

Mention  a  few  instances  of  spasmodic  stricture. 

Obstruction  of  a  sound  or  bougie  passed  in  the  healthy  urethra 
of  a  young  man  for  the  first  time,  inability  to  pass  water  from 
some  nervous  trouble,  as  fear,  shame,  anxiety,  etc. 

What  are  the  points  in  diagnosis  of  spasmodic  stricture  of  the 
urethra  ? 

It  always  occurs  suddenly.  The  stream  of  urine,  while  small 
during,  is  of  normal  size  after,  the  spasms,  and  when  it  occurs  in 
the  introduction  of  a  sound  so  as  to  obstruct  its  passage,  gentle 
pressure  of  the  sound  against  the  contracting  urethra  will  generally 
overcome  the  spasm  and  allow  its  entrance  into  the  bladder. 

What  is  the  treatment? 

Removal  of  the  cause  when  it  is  discovered  is  the  first  principle 
upon  which  to  work.  The  spasm  is  often  relieved  by  a  hot  bath 
or  by  the  local  application  of  heat  or  cold,  or  more  effectively  by 
the  use  of  an  anaesthetic. 


STRICTURE   OF   THE    URETHRA.  57 

What  are  the  different  forms  of  organic  stricture  ? 

(1)  It  may  simply  be  a  linear  fold  or  band  surrounding  the 
urethra  in  a  transverse  or  oblique  direction  in  one  or  more  posi- 
tions. 

(2)  The  same  condition  may  exist  in  the  form  of  a  flat  band 
to  the  extent  of  about  a  quarter  of  an  inch  surrounding  the  canal. 

(3)  It  may  consist  of  more  or  less  irregular,  contracted,  and 
nodular  cicatrical  tissues. 

Where  does  a  stricture  generally  develop? 

It  generally  surrounds  a  congested  or  inflamed  area  the  remnant 
of  a  gonorrhoea  or  the  result  of  an  injury. 

How  is  this  to  be  explained  ? 

In  inflammations  of  other  portions  of  the  body,  such  as  in  joints 
or  in  the  sheaths  of  tendons,  the  natural  tendency  is  to  quiet  and 
temporarily  discontinue  the  function  of  the  affected  portion,  and 
during  the  period  of  rest,  as  a  result  of  the  discontinuance  of  use, 
the  joint  or  muscle  becomes  more  or  less  stifle  from  the  throwing 
out  of  lymphatic  material  around  the  affected  area.  If  there 
were  no  means  of  restoring  the  joint  to  its  regular  function,  this 
thrown-out  material  would  be  permanent  here  as  it  is  in  the  ure- 
thra. We  have  as  a  result  of  the  different  causes  already  men- 
tioned spots  of  inflammation  or  ulceration  in  one  or  more  portions 
of  the  canal.  These  may  or  may  not  succumb  to  the  regular 
modes  of  treatment  ordinarily  pursued  at  the  present  day,  but  as 
a  result  of  the  diseased  condition  of  these  portions  of  the  urethra 
and  partial  disuse  of  the  contractile  fibres  which  surround  it,  as 
in  the  case  already  mentioned  of  joint  disease,  there  is  thrown  out 
a  lymphatic  material  surrounding  the  affected  area.  The  extent  to 
which  this  condition  may  exist  and  be  permanently  cured  cannot  be 
definitely  stated,  but  in  a  general  way  it  may  be  said  to  be  permanent 
when  once  fairly  started,  as  the  condition  itself  tends  to  encourage 
an  increase.  There  are  probably  certain  cases  and  conditions  which 
in  different  individuals  tend  to  increase  or  hasten  this  fibrous  condi- 
tion, which  may  be  found  in  the  irritating  state  of  the  urine,  the 
use  of  unnecessarily  strong  injections,  and  extension  of  the  in- 
flamed area. 

What  are  the  number  of  strictures  generally  found  in  one  indi- 
vidual ? 

There  is  generally  one,  although  two  or  more  may  exist. 


58  GONOERHCEA. 

What  are  the  most  common  seats  of  stricture  of  the  urethra  ? 

Probably  the  most  common  seats  of  stricture  are  the  bulbo- 
membranous  junction  and  the  fossa  navicularis. 

What  are  the  causes  of  organic  stricture  ? 

Stricture  may  be  congenital.  Otherwise,  organic  stricture  is 
always  caused  by  injury  or  inflammation.  Inflammation  (gonor- 
rhceal)  is  the  most  common  cause. 

What  is  the  pathology  of  stricture  in  its  simplest  form  ? 

The  tissue-change  may  be  a  mere  thickening  of  the  mucous 
membrane  like  a  linear  scar,  or  if  more  advanced  a  patch  of  car- 
tilaginous hard  material,  which  is  an  extension  or  aggravation  of 
the  simple  variety,  consisting  of  a  thickening  of  newly-formed  tis- 
sue over  a  proliferation  of  the  cell-elements  by  a  continual  chronic 
inflammation.  This  process  takes  place  beneath  the  mucous  mem- 
brane, and  not  on  its  surface.  The  stricture,  then,  when  very  slight, 
is  merely  a  linear  ring  surrounding  the  canal,  or  it  may  be  a  dense 
mass  of  fibrous  and  callous  material  encircling  the  canal  and  hold- 
ing it  in  a  permanently  contracted  condition  ;  or,  on  the  other  hand, 
the  tissue  may  be  cartilaginous,  exuberant,  and  of  an  uneven,  nodu- 
lar distribution.  Added  to  these  different  conditions  there  may  be 
also  bands  and  flattened  nodules. 

How  long  after  an  attack  of  gonorrhoea  has  run  a  persistent  course 
may  stricture  be  suspected? 

It  may  commence  to  form  within  one  year  or  not  until  several 
years  have  elapsed.  Generally  speaking,  in  any  case  of  an  ure- 
thral discharge  which  has  continued  to  flow  for  a  period  of  from 
eight  months  to  a  year  or  longer,  stricture  should  be  searched  for. 

What  is  the  proper  method  of  exploring  the  urethra  with  the 
idea  of  discovering  whether  a  stricture  be  present  ? 
A  blunt  steel  instrument  may  be  used,  of  the  largest  size  which 
may  comfortably  be  introduced  into  the  meatus,  having  been  pre- 
viously warmed  and  lubricated.  This  may  be  introduced  until  met 
by  some  obstruction,  upon  which  the  instrument  is  removed  and 
another  smaller  one  selected  and  passed  up  to  the  obstruction.  If 
this  does  not  pass,  a  number  of  smaller  instruments,  going  down  the 
scale,  are  introduced  until  the  one  which  passes  through  the  stric- 
ture without  any  appreciable  obstruction  is  reached ;  and  this  one 
is  the  measurement  of  the  size  of  the  stricture.  When  the  sound 
which  is  small  enough  to  pass  through  the  strictured  area  is  with- 


STRICTURE    OF   THE    URETHRA,    ORGANIC.  59 

drawn  in  organic  stricture,  there  will  be  a  peculiar  grasping  of  the 
instrument,  which  is  hard  to  describe,  but  soon  becomes  familiar  to 
those  who  have  made  many  examinations.  This  is  never  felt  in  a 
case  of  spasmodic  stricture,  which  if  situated  in  the  deep  urethra 
generally  has  a  tendency  to  expel  the  instrument,  instead  of  hold- 
ing it  in  its  grasp  as  does  the  permanent  form. 

Another  way  of  examining  is  by  using  bulbous  bougies,  starting 
on  a  small  size  and  running  up  to  a  size  which  meets  with  some 
obstruction,  and  then  returning  a  size  or  two  to  the  one  which  will 
pass  through  the  stricture,  thus  measuring  the  size  of  the  stricture. 
In  general,  the  steel  curved  blunt  instruments  are  the  best  for  the 
determination  of  recent  and  slight  stricture,  and  are  less  liable  to 
fallacy  than  the  bulbous  bougies  in  these  cases  ;  whereas  in  decided 
and  extensive  stricture  the  bulbous  bougies  are  most  convenient 
for  their  examination  and  measurement.  The  bulbous  instrument 
when  withdrawn,  if  there  be  an  inflammatory  area  on  or  around 
the  stricture,  will  generally  be  found  to  contain  a  drop  of  pus 
and  blood  on  the  rounded  edge  of  the  bulb.  The  urethrometer  is 
an  instrument  devised  for  measuring  the  urethral  calibre,  and  con- 
sequently for  the  diagnosis  of  stricture.  It  is  best  described  by  an 
illustration  (Fig.  5).     The  size  of  the  bulb  at  the  lower  end  (rubber 

Fig.  5. 


Urethrometer. 


caps  made  to  fit  the  wire  frame  accompanying  the  instrument)  is 
enlarged  or  contracted  by  the  screw  at  the  top.  When  used  it 
should  be  screwed  down  to  its  smallest  size,  passed  to  the  bottom 
of  the  urethra,  then  screwed  up  to  normal  calibre  ;  and  in  withdraw- 
ing any  variation  from  this  size  can  be  detected. 

What  are  the  dangers  of  urethral  examination? 

If  it  be  not  pursued  with  proper  delicacy  and  care,  damage  may 
be  done  to  the  delicate  urethra,  and  there  is  danger  of  producing  a 
false  passage  with  the  point  of  the  instrument,  and  thus  be  entirely 
off  the  path  to  the  bladder.     Such  mistakes  may  result  in  increas- 


60  GONOREHCEA. 

ing  the  strictured  area  or  in  producing  peri-urethral  inflammation 
and  abscess.  There  is  also  a  danger  of  causing  so-called  "  urethral 
fever  "  and  chill  susceptibility  to  which  seems  to  vary  in  different 
individuals. 

Of  what  does  this  urethral  fever  consist  ? 

Different  explanations  have  been  made,  and  the  cause,  on  account 
of  the  difference  of  opinion,  cannot  be  definitely  given.  It  may  be 
an  absorption  of  septic  material  or  a  reflex  impression  made  through 
the  sympathetic  nervous  system  by  peripheral  irritation. 

May  some  individuals  be  subject  to  a  greater  amount  of  interfer- 
ence in  this  region  than  others  ? 

While  in  some  the  most  trivial  interference  by  instruments  seems 
to  bring  on  this  peculiar  condition,  others  seem  to  tolerate  all  man- 
ner of  instrumentation,  and  those  who  at  first  are  sensitive  to  the 
use  of  instruments  may  in  time  be  made  to  tolerate  them. 

What  precautions  should  be  taken  in  making  exploratory  exami- 
nations of  the  urethra  ? 

As  septic  absorption  is  one  of  the  theories  of  causation  of  this 
condition,  whether  it  be  accepted  or  not,  antiseptic  precaution  is  a 
proper  expedient. 

The  instruments  should  be  scrupulously  clean  if  not  sterilized. 
At  the  first  sitting  there  is  no  limit  to  the  delicacy  and  care  with 
which  the  instruments  should  be  introduced,  and  it  is  better  to 
send  a  patient  away,  after  an  unsatisfactory  examination,  and  have 
him  return,  than  to  run  too  great  a  chance  of  producing  urethral 
fever. 

Are  there  any  drugs  which  succeed  in  warding  off  an  urethral  chill 
after  examination? 

Quinine  was  formerly  used,  and  by  some  it  is  held  still  in  esteem, 
but  with  others  it  has  fallen  into  disrepute,  as  the  number  of  cases 
in  which,  after  its  administration,  the  urethral  chill  has  occurred  is 
great  enough  to  make  those  cases,  where  no  chill  has  occurred  free 
from  this  after-result  by  coincidence  only.  Of  late  two  new  drugs 
have  been  introduced  into  the  materia  medica  of  urethral  surgery, 
which  may  have  just  claim  of  lessening  the  severity  of,  if  not 
entirely  preventing,  this  peculiar  disturbance  following  urethral 
exploration.  They  are  salol  and  diuretin.  The  former  is  given 
by  way  of  purifying  and  sterilizing  the  urine ;  the  other  is  of  too 
recent  introduction  to   state  here  its  physiological   action   or  its 


STRICTURE    OF   THE    URETHRA. SYMPTOMS.  61 

special  effect  in  preventing  the  condition  in  question.  Substantial 
reports,  however,  go  to  show  that,  whatever  be  the  cause  of  this 
condition,  and  whatever  the  effect  of  this  drug,  its  use  has  been 
accompanied  by  a  freedom  from  the  urethral  fever  which  has 
seemed  to  be  greater  than  has  previously  been  experienced  with 
other  drugs. 

How  should  diuretin  be  used  after  an  examination  for  the  purpose 
of  preventing  urethral  chill  ? 

If  possible,  one  dose  of  10  gr.  should  be  given  one  hour  before 
the  examination,  followed  up  every  two  hours  by  a  repetition  of 
the  same,  according  to  the  severity  of  the  examination  and  the 
condition  of  the  patient.  If  desired,  it  may  be  kept  up  for  twenty- 
four  hours,  but  this  is  probably  never  required  after  an  examina- 
tion. 

What  are  the  symptoms  of  stricture  ? 

Stricture  may  exist  a  long  time  without  giving  rise  to  any  symp- 
toms of  obstruction  or  discomfort.  There  generally  exists  a  small 
amount  of  gleety  discharge  from  a  congested  condition  existing  on 
the  surface  of  the  constricted  area.  This  may  be  very  slight,  so 
that  it  may  be  entirely  unnoticeable  ;  or  if  the  urethra  be  sub- 
jected to  any  amount  of  irritation,  as  a  result  of  excessive  drink- 
ing, etc.,  the  discharge  may  be  very  profuse  and  resemble  an  acute 
urethritis,  and  be  taken  for  a  fresh  attack  of  gonorrhoea.  The 
strictured  area,  acting  more  or  less  as  an  obstruction  to  the  out- 
ward passage  of  the  urine,  causes  a  narrowing  of  the  stream 
according  to  the  extent  of  the  constriction,  and  in  a  slowly-form- 
ing stricture  the  gradual  narrowing  of  the  stream  may  be  the 
only  symptom  noticed  by  the  patient  during  a  period  of  years. 
There  may  or  may  not  be  frequent  urination.  This  will  depend 
upon  the  condition  of  the  deep  urethra  and  the  mind  of  the  patient, 
both  of  which  may  act  as  stimulants  to  the  frequent  flow  of  the 
urine. 

As  the  stricture  progresses,  what  other  symptoms  may  be  discov- 
ered? 

A  cartilaginous  hardness  may  be  felt  from  the  outside  at  the 
constricted  portion,  and  the  opening  at  the  meatus  may  look  blue 
and  congested  from  obstructed  circulation.  The  stream  becomes 
small,  and  is  often  forked  or  twisted  like  a  corkscrew  just  after 
leaving  the  meatus,  or  there  may  be  two  or  more  streams  running 


62  GONORRHCEA. 

in  different  directions.  The  last  few  drops  of  urine  are  retained 
within  the  canal  and  dribble  after  urination.  If  the  amount  of 
strictured  tissue  formed  be  -great,  erection  is  often  quite  painful. 

STRICTURE   OF   THE  URETHRA.— TREATMENT. 

What  are  the  different  modes  of  treatment  for  stricture  of  the 
urethra  ? 

Dilatation,  divulsion  or  rapid  dilatation,  electrolysis,  urethrotomy 

or  division  of  the  strictured  area. 

What  are  the  different  kinds  of  urethrotomy  ? 

Internal  urethrotomy,  or  division  of  the  stricture  by  means  of 
an  instrument  passed  through  the  meatus  to  the  point  of  stricture, 
and  external  urethrotomy,  or  division  of  the  stricture  externally, 
reached  through  the  perineum. 

In  general  terms,  when  are  these  two  methods  applicable? 

In  strictures  of  the  anterior  or  pendulous  urethra  internal  ure- 
throtomy is  used  ;  in  strictures  of  the  deep  canal  external  urethrot- 
omy or  perineal  section  is  best,  being  the  safest  and  most  satis- 
factory. 

How  deep  in  the  anterior  urethra  may  internal  urethrotomy  be 
resorted  to? 

It  is  hardly  advisable  to  cut  internally  deeper  than  from  4J  to 
5  inches. 

What  is  the  danger  of  cutting  deeper  by  the  internal  method  ? 

There  seems  to  be  a  greater  liability  to  the  occurrence  of  ure- 
thral chill  and  suppression  of  the  urine  when  the  deep  urethra  is 
cut  without  making  provision  for  the  continuous  outward  flow  of 
urine — namely,  by  division  through  the  perineum,  and  preferably 
by  the  introduction  of  a  perineal  tube  for  drainage  of  the  bladder. 

How  is  dilatation  employed  in  stricture  ? 

After  determining  the  sized  instrument  which  will  readily  pass 
through  the  strictured  area,  the  next  largest  size  is  introduced, 
which  will  produce  a  partial  dilatation.  One  or  two  sizes  larger 
are  then  employed,  and  the  patient  is  told  to  return  about  two 
days  later,  at  which  time  it  is  better  to  commence  with  an  instru- 
ment one  size  smaller  than  was  last  introduced,  as  the  stricture  is 
apt  to  undergo  a  partial  recontraction,  and  then  the  sizes  are  run 


STRICTURE   OF    THE    URETHRA. TREATMENT.  63 

up  again  as  at  the  first  time.     This  is  kept  up  until  the  normal 
calibre  is  reached  by  the  use  of  a  full-sized  instrument. 

Is  there  any  rule  to  direct  us  as  to  the  normal  size  of  any  indi- 
vidual urethra? 

There  is  a  rule — that  of  Otis — which,  roughly  given,  is  that  a 
penis  3  inches  in  diameter  should  receive  through  its  urethra  a 
No.  30  instrument  of  the  French  scale,  and  that  each  I  of  an  inch 
cfver  3  inches  in  the  size  of  the  penis  should  add  2  sizes  to  the 
number  on  the  scale  of  sounds  which  should  normally  be  taken  by 
the  urethra  in  hand. 

What  kind  of  instruments  are  best  used  for  dilatation  ? 

The  conical  steel  instruments  or  sounds  are  generally  adopted 
for  this  purpose,  as  the  narrow  end  can  be  more  readily  engaged 
within  the  constriction,  and  dilatation  up  to  the  full  size  of  the  instru- 
ment be  gradually  effected.  Straight  steel  instruments  are  some- 
times employed,  but  are  not  so  serviceable  as  the  curved  ones,  as 
with  the  latter,  after  a  full  introduction,  rotation  of  the  instrument 
will  decide  whether  the  bladder  has  been  reached,  and  the  danger  of 
making  and  enlarging  a  false  passage  will  be  obviated ;  also,  it  is 
of  advantage  at  the  same  time,  in  dilating  the  stricture,  to  treat  the 
deep  urethra  by  the  gentle  and  uniform  pressure  which  these  sounds 
will  afford.  Hard-rubber  flexible  bougies  with  tapering  ends  are 
also  made,  and  used  by  some  for  the  purpose  of  dilating  the  stric- 
ture, but  they  are  not  so  effective  nor  so  desirable  for  this  purpose  as 
the  curved  steel  instrument.  There  are  two  kinds  of  flexible  instru- 
ments, the  English  and  the  French.  The  French  are  more  flexible 
than  the  English,  and  flexibility  makes  them  desirable  for  some  pur- 
poses. The  English  elastic  instrument  is  valuable  in  that  it  will 
preserve  any  curve  given  to  it  when  heated  after  it  is  cold.  Per- 
haps these  flexible  instruments  are  safer  to  put  into  the  hands  of 
the  patients,  as  they  are  liable  to  do  less  harm  with  them,  having 
the  tendency  to  bend  when  met  by  an  obstruction,  instead  of  push- 
ing everything  before  them,  as  do  the  steel  instruments. 

What  are  the  naturally-contracted  portions  of  the  urethra  which 
should  not  he  confounded  with  an  acquired  condition,  and  are 
sometimes  misleading? 

Just  within  the  meatus,  about  an  eighth  to  a  quarter  of  an  inch, 
there  is  a  point  of  congenital  narrowing,  and  it  is  sometimes  cut, 
when  unusually  small,  for  the  purpose  of  allowing  an  instrument 


64  GONORRHCEA. 

to  be  passed,  but  otherwise  it  is  of  no  account.  There  is  also  another 
natural  point  of  narrowing  at  the  bulbo-membranous  junction. 
Thus  it  is  seen  that  the  natural  urethra  is  never  uniformly  the 
same  size  throughout,  and  an  effort  to  establish  a  uniform  calibre 
must  necessarily  require  a  division  of  these  constricted  portions, 
which  may  often  be  perfectly  innocent  in  the  causation  of  a  chronic 
urethral  stricture. 

INTERNAL  URETHROTOMY. 

How  is  internal  urethrotomy,  or  inward  division   of  stricture, 
effected  ? 

By  the  bistoury  when  near  the  external  meatus,  and  by  the  ure- 
throtome when  deeper  than,  say,  1  to  2  inches.  The  urethrotomes 
used  at  the  present  day  are  the  Otis  or  Wyeth's  instruments,  which 
distend  the  passage  at  the  same  time  that  the  incision  is  made.  The 
urethrotome  of  Maisonneuve  was  formerly  adopted,  but  has  at  the 
present  day  fallen  more  or  less  into  disuse.  This  latter  instrument 
has  not  the  advantage  of  the  Otis  of  dilating  as  well  as  cutting 
(Fig.   6),  but  is  constructed  with  a  blunt  point  on  a  triangular 

Fig.  6. 


Otis's  Urethrotome. 


knife  placed  on  a  side  of  a  wire  or  steel  bar ;  which  blunt  point, 
coming  in  contact  with  the  strictured  area,  sinks  deeply  into  the 
healthy  portion,  whereas  the  knife  receives  on  its  cutting  edge 
the  obstructing  tissue. 

How  is  internal  urethrotomy  effected  by  means  of  the  dilating 
urethrotome  ? 

The  stricture  having  been  measured  both  as  to  depth  and  calibre, 
the  instrument  is  introduced  to  the  bottom  of  the  urethra  and  the 
screw  at  the  top  turned,  which  controls  the  dilating  portion,  up  to 
the  size  which  is  normal  to  the  case  in  hand  ;  or  if  the  stricture  be 
very  cartilaginous  and  tight  within  several  degrees  of  the  normal 


TKEATMENT   OF   STRICTURE    BY    DIVULSION.  65 

point,  the  knife  is  then  drawn  out,  up  to  and  through  the  strictured 
area,  but  never  entirely  out  of  the  instrument.  The  detection  of 
the  stricture  by  the  knife  is  felt  by  a  practised  hand  in  the  density 
of  the  tissue  which  is  being  cut,  so  that  it  can  be  appreciated  by 
the  operator  when  he  has  entirely  passed  through.  Having  made 
the  primary  cut,  the  dilating  screw  is  again  turned  up  to  a  few 
degrees  beyond  the  natural  size  of  the  urethra,  and  another  cut 
with  the  knife  is  made,  and  if  the  stricture  be  entirely  divided  it 
will  be  appreciated  by  the  softness  of  the  tissue  into  which  the 
knife  enters.  The  instrument  is  then  withdrawn,  and  a  steel  sound, 
the  full  size  of  the  urethra  or  a  couple  of  sizes  larger,  is  passed 
down  to,  but  not  through,  the  deep  urethra,  as  there  seems  to  be  a 
greater  tendency  to  urethral  chill  following  this  operation  when  the 
deep  urethra  is  traversed  after  the  cutting. 

After  the  operation  a  sound  of  about  the  size  of  that  to  which 
the  stricture  has  been  cut  should  be  passed  every  two  or  three  days 
for  the  first  two  weeks  through  the  stricture  only,  and  subsequently, 
at  intervals  varying  from  two  weeks  to  a  month,  into  the  bladder 
for  a  period  of  about  six  months.  This  may  be  done  by  the  patient 
himself.  Finally,  it  is  well  to  recommend  the  patient  to  return  after 
a  period  of  several  months  has  elapsed  without  the  passage  of 
sounds,  to  be  examined  for  a  possible  recontraction. 

TREATMENT  OF   STRICTURE  BY  DIVULSION. 

Divulsion  of  stricture  is  an  unnecessarily  rough  procedure,  and 
while  it  was  used  more  or  less  formerly,  since  the  invention  and  per- 

FiG.  7. 


Urethral  Dilator. 


fection  of  the  urethrotome  it  is  fast  losing  favor.    Divulsion  is  effected 
by  an  instrument  which  was  originally  devised  for  rapid  dilatation 
with  tearing,  but,  adapted  as  a  divulsor,  it  is  made  to  stretch  to  the 
5— G-U. 


GQ  GONOKKHCEA. 

extent  of  tearing  the  strictured  point.  The  instrument  is  depicted 
in  the  illustration  on  page  65.  The  screw-head  at  its  handle  is 
turned  so  as  to  make  the  blades  separate  laterally,  the  extent  of 
separation  being  indicated  on  a  scale  in  the  handle.  The  latest 
instrument  is  tunnelled,  so  as  to  enable  it  to  be  passed  over  a  filiform 
bougie  ;  which  advantage  renders  it  an  instrument  of  real  value  in 
cases  of  very  tight  stricture,  where  a  partial  dilatation  can  be  efiect- 
ed  by  its  means,  allowing  the  entrance  of  a  larger  instrument — the 
dilating  urethrotome,  for  instance — and  in  the  deep  urethra,  when 
the  treatment  by  dilatation  has  been  elected  to  open  the  way  for 
steel  instruments.  It  also  may  be  useful  to  pick  up  foreign  bodies 
from  the  urethra. 


ELECTROLYSIS   IN  THE  TREATMENT  OF  STRICTURE. 

The  opinions  and  belief  of  about  all  the  surgeons  of  standing  at 
the  present  day  in  regard  to  this  procedure  are  so  universally  simi- 
lar that  it  seems  hardly  necessary  to  enter  into  the  subject  other 
than  to  give  it  a  passing  notice. 

Is  it  possible  to  cure  an  organic  fibrous  stricture  by  the  use  of 
electricity  alone? 

No. 

Has  it  ever  been  shown  by  any  practical  report  of  cases  that 
such  an  end  could  be  effected? 

No. 

Is  it  reasonable  to  suppose  that  electricity  can  open  a  stricture 
and  cause  it  to  remain  permanently  open  by  effecting  the 
absorption  of  its  tissues  ? 

No. 

May  electricity  used  in  as  strong  currents  as  has  been  recom- 
mended for  electrolysis  do  damage  to  the  urethra? 

Yes. 

Is  it  probable  that  whatever  actual  benefit  reported  cases  have 
obtained  during  a  treatment  by  electrolysis  is  due  to  instru- 
mentation, and  is  the  same  which  is  often  experienced  by  a 
similar  treatment  minus  electricity? 

Yes. 


CHOICE   OF   TREATMENT    OF    ANTERIOR    STRICTURES.       67 

CHOICE  OF  TREATMENT  OF  ANTERIOR  STRICTURES. 

What  is  to  guide  the  surgeon  in  the  choice  between  cutting  or 
stretching  the  strictures  of  the  anterior  urethra  ? 

It  will  depend  partly  upon  the  patient,  and  partly  upon  the  stric- 
ture and  the  symptoms  accompanying  it.  If  the  stricture  be  recent 
and  of  large  calibre,  the  symptoms  accompanying  it  being  perhaps 
only  a  slight  gleet  with  no  obstruction  to  the  urinary  flow,  dilata- 
tion should  always  be  first  resorted  to,  and  by  the  curved  steel 
instruments,  which  may  also  favorably  affect  the  deep  canal. 

Is  the  discharge  accompanying  stricture  of  the  urethra  necessa- 
rily dependent  upon  this  condition? 

No ;  it  is  often  referable  to  a  congested  or  eroded  condition  of 
the  deep  urethra,  and  dilatation  or  division  of  the  stricture  may  still 
leave  the  gleet  behind  it.  A  promise,  therefore,  that  an  operation 
or  full  dilatation  of  an  anterior  stricture  will  result  in  removal  of 
the  accompanying  gleet  can  never  be  wisely  given.  If  the  stric- 
ture be  one  of  great  density  and  one  that  interferes  with  the  free 
passage  of  the  urine,  thus  possibly  tending  to  an  incomplete  empty- 
ing of  the  bladder  and  debilitating  its  action  by  throwing  too  much 
work  upon  it,  operation  by  internal  urethrotomy  can  be  properly 
advised,  although  the  gleety  symptom,  which  is  generally  the  most 
offensive  to  the  patient,  is  not  necessarily  removed  by  this  proce- 
dure. 

"What  are  the  chances  for  permanent  cure  of  anterior  stricture  ? 

Stricture  is  said  to  be  a  permanent  afi"air,  and  once  acquired  can 
never  be  removed ;  but,  since  the  later  improvements  in  the  opera- 
tion of  internal  urethrotomy,  statistics  seem  to  show  that,  by  this 
method,  although  cure  and  permanent  relief  from  symptoms  are 
not  always  constant,  yet  in  a  great  number  of  cases,  where  the  ope- 
ration is  properly  performed,  recontraction  does  not  occur  and  other 
manifestations  disappear. 

In  what  manner  does  internal  urethrotomy  cure  stricture  ? 

By  terminating  the  recontraction  of  the  strictured  area  and  con- 
tinual narrowing  of  the  canal,  which  is  apt  to  occur  when  dilatation 
is  left  off",  it  being  one  of  the  properties  of  stricture  thus  to  recur. 

Does  dilatation  ever  cure  stricture? 

While  it  cannot  be  said  that  stricture  is  cured  through  this  pro- 
cedure, permanent  relief  is  claimed  to  have  been  obtained  in  certain 


68  GONORRHGEA. 

cases,  and  for  this  reason  it  is  best  adapted  in  simple  and  recent 
forms. 

What  portion  of  the  urethra  should  be  divided— the  floor  or  the 
roof? 

In  strictures  at  or  near  the  meatus  division  may  be  made  upon 
the  floor,  but  in  all  strictures  below  this  point  division  should  be 
made  upon  the  roof. 

What  method  of  treatment  should  be  chosen  for  strictures  of  the 
deep  urethra? 

As  dilatation  offers  no  reliable  promise  of  radical  relief,  when 
treatment  is  pursued  with  this  idea  in  view  it  is  useless  to  consider 
dilatation ;  but  the  operation  necessary  for  strictures  in  the  deep  por- 
tions of  the  urethra  is  not  such  a  simple  one  as  internal  urethrot- 
omy, and  is  a  more  formidable  affair  and  more  apt  to  be  accompanied 
by  hemorrhage  and  shock  ;  therefore,  if  the  patient  be  satisfied  with 
a  condition  of  affairs  which  leaves  him  with  a  full-sized  urethra, 
allowing  free  passage  of  the  urine,  and  is  willing  to  follow  up  the 
use  of  a  sound  for  the  rest  of  his  life,  dilatation  can  offer  this  much 
comfort  and  consolation  ;  but  in  cases  where  the  individual  is  will- 
ing to  take  greater  risks  for  the  purpose  of  having  greater  chances 
of  radical  and  permanent  relief,  external  urethrotomy  is  the  only 
means  which  can  give  him  any  promise ;  and  even  this  operation,  it 
must  be  remembered,  is  not  necessarily  met  with  success. 

EXTERNAL  URETHROTOMY. 

What  are  the  steps  in  this  operation,  and  what  are  the  condi- 
tions which  render  it  a  simple  and  straightforward  procedure 
or  a  difficult  and  complicated  one  ? 

Strictures  of  the  deep  urethra  may  be  of  variable  size,  and  allow 
the  passage  of  an  instrument  into  the  bladder,  small  or  of  moderate 
size,  which  in  either  event  will  act  as  a  guide  for  the  external  incision 
of  the  operation  ;  but  in  old  strictures  of  long  duration,  which  have 
become  suddenly  impassable  from  some  cause  or  other,  allowing 
neither  the  passage  of  the  water  from  within  nor  of  an  instrument 
from  without,  the  operation  must  then  be  done  "  without  a  guide  " 
through  the  course  of  the  urethra  where  the  stricture  exists ;  and 
this  is  a  much  more  serious  and  difficult  undertaking,  and  is  dis- 
tinguished from  the  former  operation  by  the  name  of  "  perineal 
section,"  In  strictures  where  an  instrument  of  moderate  size  can 
be  readily  passed  into  the  bladder  a  grooved  instrument  or  staff  is 


EXTERNAL   URETHROTOMY.  69 

used,  and  after  introduction  is  held  by  an  assistant  in  a  perpendicu- 
lar position  directly  in  the  median  line  of  the  body.  The  operator 
then  cuts  down  upon  this  staff  until  the  groove  is  reached,  making 
a  free  incision  externally  and  endeavoring  to  reach  the  groove  with 
the  point  of  his  knife.  When  this  is  felt  by  the  assistant  the  staff 
is  partially  removed.  The  operator,  with  his  finger  in  the  rectum, 
having  found  the  urethra,  changes  his  knife  for  a  blunt  bistoury  or 
blizzard  knife,  with  which  as  the  staff  is  being  removed  he  cuts  his 
way  along  the  course  of  the  urethra  to  the  bladder.  The  strictured 
area  should  be  cut  upon  the  floor  as  well  as  upon  the  roof.  If  stric- 
tures of  the  anterior  urethra  accompany  those  of  the  deep  portion,  a 
urethrotome  is  introduced  and  the  normal  calibre  of  the  urethra  estab- 
lished throughout.  A  sound  much  in  excess  of  the  normal  calibre, 
to  stretch  the  entire  urethra,  is  then  passed  into  the  bladder.  The 
hemorrhage  in  simple  operations  is  slight  unless  the  bulb  of  the 
urethra  be  invaded  to  a  great  extent,  and  can  generally  be  stopped 
by  hot  water  and  moderate  packing.  A  perineal  tube  of  large 
enough  calibre  to  ensure  the  non-passage  of  urine  between  it  and 
the  walls  of  the  urethra  is  introduced  through  the  perineal  wound, 
and  tied  in  place  to  protect  the  deep  urethra  for  the  first  forty-eight 
hours.  In  simple  linear  stricture,  or  stricture  of  moderate  bands 
surrounding  the  canal,  incision  through  the  strictured  area  in  the 
floor  and  roof  of  the  canal  is  all  that  is  necessary ;  but  where  the 
amount  of  cicatricial  tissue  is  excessive  or  nodular,  excision  of  this 
is  called  for,  and  when  the  loss  is  great,  a  transplantation  of  the 
mucous  membrane  by  Thiersch's  method  is  indicated.  This  latter 
consists  of  transferring  a  piece  of  healthy  mucous  membrane  from 
another  portion  of  the  body  of  the  patient  or  from  an  external 
source,  and  restraining  it  in  position  by  means  of  catgut  sutures. 

What  medication,  etc.  should  be  adopted  during  the  course  and 
treatment  of  a  case  by  this  operation  ? 

It  is  well  for  forty-eight  hours  before  the  operation  to  put  the 
patient  on  10  grains  of  salol  every  six  hours  or  four  times  a  day, 
and  about  twelve  hours  before  to  give  10  grains  of  diuretin  every 
two  hours.  These  measures  may  be  kept  up  for  a  few  days  after  the 
operation,  or  until  such  time  as  the  patient  shows  his  kidneys  are  in 
good  working  order  and  a  protective  membrane  is  formed  over  the 
cut  area.  The  bladder  may  be  washed  before  the  operation,  as  it 
always  is  afterward,  and  this  procedure  is  kept  up  in  accordance 
with  the  amount  of  cystitis  which  exists. 


70  GONORRHCEA. 

What  causes  make  a  stricture  impassable  in  many  attempts  at 
instrumentation?  and  what  means  should  be  used  to  over- 
come this  difficulty? 

Inflammation  on  the  surface  of  a  urethra,  a  tortuous  and  twisted 
canal  with  a  very  tight  stricture,  and  incompetence  or  inexperience  of 
the  operator.  In  examining  a  urethra  with  a  tiglit  and  tortuous  canal 
or  in  an  inflamed  condition  the  greatest  delicacy  should  be  used  and 
care  in  the  choice  and  application  of  instruments.  If  this  is  not 
observed,  a  false  passage  may  be  produced  and  the  course  of  the 
canal  entirely  lost,  thus  adding  to  the  difficulty  of  passage.  If  a 
stricture  be  not  unduly  tight,  having  received  a  fair-sized  instru- 
ment previously,  inflammation  on  its  surface  may  cause  difficulty 
in  entering  or  passing  it.  In  such  a  case,  if  a  tapering  hard-rub- 
ber bougie,  well  oiled,  be  gently  introduced,  the  small  end  of  the 
instrument  may  become  engaged  in  the  stricture,  and  thus  be  read- 
ily passed  into  the  bladder.  In  all  cases  of  this  kind  too  much  care 
cannot  be  used,  as  much  force  applied  to  the  instrument  will  result 
in  a  false  passage.  Sometimes  if  the  stricture  be  small  and  has  not 
been  tampered  with  and  torn,  olive  oil  by  means  of  a  small  syringe 
can  sometimes  be  forced  through  the  stricture,  and  then  an  instru- 
ment introduced  while  the  olive  oil  is  made  to  remain  in  the  urethra. 
In  a  tortuous  and  tight  stricture  we  have  for  our  use  the  whalebone 
filiform  bougies.  These  generally  have  twisted  ends,  and  by  gentle 
usage  may  sometimes  find  the  hidden  opening  of  the  urethra  in  the 
strictured  tissue.  By  means  of  these  instruments  the  diff"erent 
portions  of  the  canal  can  be  examined  either  for  false  passages  or 
for  obstructing  bands.  As  a  false  passage  is  most  frequently  found 
on  the  floor  of  the  urethra,  on  account  of  the  spongy  and  soft  con- 
dition of  the  tissues,  one  of  these  instruments  or  a  small  flexible  rub- 
ber instrument  can  be  introduced  first,  and  made  to  fill  the  roof  of 
the  canal,  and  then  the  same  course  can  be  pursued,  filling  the  right 
side  and  the  left  side,  and  finally  the  floor.  If  none  of  these  meth- 
ods are  successful,  a  number  of  filiforms  may  be  introduced  con- 
secutively, and  perhaps  by  filling  with  these  little  instruments  the 
various  byways  and  corners,  one  out  of  the  several  introduced  may 
find  the  desired  passage.  When  the  opening  in  the  stricture  is 
found,  that  little  "grasping"  peculiar  to  this  condition  can  be  distin- 
guished ;  but  even  when  this  be  attained  the  dangers  of  false  passage 
are  not  over  and  the  difficulties  of  entrance  not  overcome,  as  a  repli- 
cated mucous  membrane  beyond  may  meet  the  instrument  after  it 
passes  the  stricture.     It  may,  however,  be  made  to  successfully 


EXTERNAL    URETHROTOMY.  71 

reacli  the  bladder  by  continual  turning,  endeavoring  to  avoid  the 
obstructions ;  but  if  it  cannot  be  passed  without  force,  it  may  be 
well  to  leave  it  several  hours  or  as  long  as  possible  within  the  grasp 
of  the  stricture,  when  it  may  be  found  to  pass  more  easily.  If  an 
instrument  be  once  successfully  introduced  into  the  bladder  through 
a  tight  stricture  of  this  kind,  it  is  advisable  not  to  remove  it,  but 
to  allow  it  to  remain  for  a  subsequent  operation,  thus  affording  a 
guide  and  doing  away  with  the  necessity  of  cutting  without  one. 
If  the  instrument  successful  in  entering  the  bladder  be  only  a  fili- 
form, grooved  sounds  have  been  devised  and  grooved  catheters  of 
various  dimensions,  one  of  which  may  be  successfully  introduced 
into  the  bladder  over  this  filiform  guide,  and  retained  for  operation, 
or  sufficient  dilatation  may  be  efiected  to  introduce  a  catheter  to 
relieve  retention.  These  tunnelled  instruments  contain  a  small 
groove  which  traverses  their  under  surface,  and  a  small  eye  at  the 
point,  through  which  the  end  of  the  filiform  is  passed,  and  the 
instrument  is  then  made  to  travel  the  whole  length  of  the  filiform, 
which  is  a  guide  for  its  passage.  The  sounds  are  hollow,  and 
have  the  advantage  of  being  able  to  prove  beyond  any  doubt 
that  the  instrument  is  in  the  bladder  by  the  withdrawal  of  a  small 
amount  of  urine.  If  there  be  doubt  as  to  whether  the  instrument 
is  in  the  bladder  or  in  a  false  passage,  a  finger  passed  into  the  rec- 
tum will  discover  the  course  the  instrument  has  taken.  If  it  be 
in  the  bladder,  the  tissues  of  the  prostate  will  be  felt  between  the 
instrument  and  the  rectum  ;  and  if  in  a  false  passage,  it  is  apt  to 
be  away  from  the  median  line,  and  the  distance  between  it  and  the 
rectum  is  measured  only  by  the  thin  walls  of  the  rectum. 

If  the  efforts  to  pass  a  stricture  have  been  throughout  unavailing 
after  long  trial  and  patience,  what  means  have  we  of  tem- 
porary relief  pending  another  attempt  at  entering  the  bladder 
or  prior  to  a  necessary  delay  in  operating  ? 

Aspiration  of  the  bladder  after  sufficient  urine  has  accumulated 
to  distend  the  organ,  so  that  its  outline  is  easily  made  out  both  by 
inspection  and  percussion  above  the  pubic  bone.  This  procedure 
is  efiected  by  piercing  the  abdominal  walls  in  the  median  line  just 
above  the  pubis  with  a  good-sized  aspirating  needle,  having  pre- 
viously carefully  cleansed  the  instrument. 

If  an  operation  be  decided  upon,  what  are  the  steps  ? 

After  the  patient  is  anaesthetized  for  the  operation,  another 
attempt  made  to  enter  the  bladder  may  be  successful,  and  a  guide 


72  GONORRHCEA. 

then  be  obtained  while  the  patient  is  in  this  relaxed  condition. 
It  is  therefore  always  advisable  to  make  this  attempt  before  pro- 
ceeding with  the  knife.  If,  however,  this  trial  is  fruitless,  a  curved 
steel  sound  or  staff  is  introduced  down  to  the  stricture,  and  its  point 
cut  upon  through  the  perineum,  after  which  the  strictured  tissue  is 
dissected  through  and  an  effort  is  made  to  find  the  urethra  beyond. 
Sometimes  when  there  is  a  great  deal  of  cicatricial  tissue  this  is 
somewhat  difficult,  as  the  canal  may  have  deviated  a  great  deal  from 
its  central  course.  After  the  right  of  way  is  established  between 
the  urethra  above  and  below  the  stricture  the  steps  in  the  operation 
are  substantially  the  same  as  in  ordinary  external  urethrotomy. 
There  is  always  a  greater  danger  of  hemorrhage,  however,  in 
perineal  section,  as  the  bulb  of  the  urethra  is  apt  to  be  largely 
invaded  by  the  incision.  This  is  generally  stopped  by  packing 
the  perineal  wound  with  an  ordinary  gauze  or  muslin  bandage 
inside  of  a  "  tent "  consisting  of  a  muslin  bag  tied  to  the  perineal 
drainage-tube  at  its  point  of  exit  from  the  wound. 

What  is  the  after-treatment  in  these  cases  ? 

In  the  way  of  medication  the  diuretin,  in  about  10-grain  doses 
every  two  hours,  is  continued  until  the  kidneys  show  no  signs  of 
restrained  action ;  salol,  5  grains  every  six  hours  for  the  first  few 
days  ;  anodynes  in  sufficient  quantity  to  overcome  spasm,  and  what- 
ever else  special  indications  may  require.  The  bladder  is  generally 
washed  at  least  once  a  day  for  the  first  few  days  in  all  cases,  and 
if  there  has  been  much  cystitis  a  greater  number  of  times  a  day  is 
advisable.  At  the  end  of  forty-eight  hours  a  good-sized  instrument 
is  introduced,  and  again  two  days  later,  and  repeated  every  two  or 
three  days  for  two  weeks,  after  which  the  intervals  are  increased 
and  a  sound  passed  about  once  a  week  for  some  time,  when  the 
intervals  may  be  increased  to  even  a  longer  time,  but  it  is  best  to 
continue  the  use  of  a  sound  at  intervals  from  a  few  weeks  to  a 
month  for  about  the  first  year  after  the  operation,  when  a  trial  may 
be  made  to  determine  whether  or  not  the  stricture  recontracts,  in 
which  case  the  sound  must  be  passed  indefinitely  at  the  intervals 
necessary  to  keep  the  urethra  up  to  a  standard  size ;  and  the  dis- 
continuance of  the  instrument  can  only  be  advised  in  cases  which 
for  several  months  or  a  year  after  this  show  no  signs  of  recontrac- 
tion,  and  even  then  it  is  well  to  have  the  patient  return  after  a 
period  of  some  length  of  time  to  submit  to  an  examination. 


EXTERNAL   URETHROTOMY — AFTER-TREATMENT.         73 

What  are  the  results  of  stricture  of  the  urethra  ? 

The  immediate  and  constant  results  which  follow  stricture  are 
simply  those  of  obstruction  to  the  urine  or  semen,  which  becomes 
evident  according  to  the  extent  of  the  stricture  and  the  condition 
of  the  patient.  Among  the  most  frequent  and  important  indirect 
results  accompanying  stricture  is  retention  of  urine,  which  may 
come  from  a  very  tight  or  from  a  moderately  tight  stricture,  nar- 
rowed by  the  existence  of  inflammation  caused  by  the  indiscretion 
of  the  patient,  excesses  in  drink,  or  cold,  and  as  a  result  of  this 
condition  the  bladder  becomes  over-distended;  if  this  condition  is 
allowed  to  continue,  it  will  permanently  impair  the  contractile  power 
of  the  bladder  and  produce  what  is  called  atony.  Retention  may  be 
the  first  symptom  or  result  of  stricture  which  presses  the  patient  to 
take  medical  advice.  If  retention  does  not  occur,  and  inflammation 
has  been  caused  on  the  surface  of  a  stricture  by  the  indiscretion 
of  the  patient,  this  inflammation  may  travel  back  over  the  stricture 
through  the  prostatic  urethra  into  the  bladder,  and  we  have  what  is 
called  cystitis  of  the  neck  of  the  bladder.  An  inflammation  of  this 
portion  of  the  tract  occasions  the  symptom  of  frequent  micturition 
in  a  greater  or  less  degree  according  to  the  degree  of  the  inflammation. 
Hgematuria  is  occasioned  sometimes  by  the  presence  of  a  stricture, 
and  may  be  the  first  symptom  which  calls  the  attention  of  the 
patient.  Certain  pains  of  a  reflex  character  may  be  present,  either 
in  connection  with  the  exercise  of  the  physiological  function  or 
without  such  connection. 

Extravasation  of  urine  is  one  of  the  most  dangerous  and  ap- 
palling results  of  stricture.  A  urethra  which  has  become  thin 
through  ulceration  breaks  during  the  effort  of  a  violent  straining, 
and  allows  the  urine  to  escape  into  the  tissues  around  the  canal. 

What  are  the  symptoms  of  this  condition  ? 

The  patient  is  sometimes  conscious  of  something  having  given 
way,  and  a  certain  amount  of  relief  is  often  felt  when  the  bladder 
previous  to  this  course  has  been  for  some  time  over-distended.  The 
amount  of  extravasation  may  be  small  or  large,  and  if  it  be  small 
such  a  condition  need  not  be  suspected  until  abscess  has  formed. 
When  the  extravasation  is  large,  its  presence  is  indicated  by  the 
feeling  of  a  hard  lump  around  the  urethra  which  may  either  be- 
come enlarged  or  form  an  abscess.  When  it  enlarges  extensively, 
infiltration  of  the  urine  takes  place,  in  which  case  it  may  take  one 
of  several  directions :  It  may  travel  into  the  tissue  of  the  corpus 


74  GONORRHCEA. 

spongiosum  and  cause  sloughing  of  the  penis,  or,  without  pene- 
trating the  spongy  body,  it  may  travel  on  its  surface,  forming  a 
fistulous  track  and  opening  near  the  glans.  It  may  extravasate 
behind  the  triangular  ligament  and  infiltrate  the  tissues  around  the 
prostate  and  rectum,  or  possibly  travel  up  behind  the  pubes  in 
the  tissue  of  the  hypogastrium.  If  it  escapes  outside  of  the  com- 
mon fascia  of  the  penis  and  in  front  of  the  triangular  ligament,  it 
will  gradually  distend  the  perineum  and  the  scrotum,  the  sub- 
cutaneous tissue  of  the  penis,  and  may  mount  up  on  the  ab- 
domen. 

What  are  the  symptoms  which  accompany  this  complication? 

They  are  those  of  shock.  A  chill  usually  forewarns,  which  is 
followed  by  general  depression,  rapid  and  irregular  pulse,  and 
symptoms  of  septicaemia. 

How  and  what  are  the  fistulse  formed  with  infiltration  of  the 
urine? 

They  are  the  natural  effort  on  the  part  of  the  urine  to  obtain 
an  external  outlet,  and  after  opening  do  not  close  until  the  natural 
outlet  has  been  re-established,  or  they  may  be  caused  by  the  for- 
mation of  abscesses  from  infiltration,  which  abscesses  make  the 
external  opening  and  narrow  down  to  fistulas. 

What  other  complication  of  stricture  having  analogous  symptoms 
occurs  ? 

Rupture  of  the  bladder. 

What  course  may  the  urine  take  here  ? 

In  some  cases  the  urine  may  escape  into  the  peritoneal  cavity, 
usually  the  result  of  an  existing  sacculus,  or  it  may  escape  into 
the  subperitoneal  tissue,  as  in  infiltration,  behind  the  triangular 
ligament. 

What  other  complications  or  results  of  stricture  occur  ? 

Abscess  of  the  prostate  may  occur  as  an  extension  of  inflamma- 
tion into  the  interstitial  tissues,  or  the  inflammation  may  extend 
through  the  ejaculatory  ducts  to  the  seminal  vessels.  Epididy- 
mitis may  affect  one  or  both  testicles.  It  sometimes  leaves  behind 
it  an  induration  of  the  canal  and  subsequent  sterility.  Constitu- 
tional symptoms  and  complications  vary  and  depend  upon  the 
existence  or  absence  of  local  complications,  such  as  cystitis,  epidid- 
ymitis, etc.  Under  such  circumstances  the  symptoms  are  those  of 
general  debility. 


GENITO-URINARY    DISEASES XOX-YEXEREAL.  75 

What  are  the  proper  measures  to  be  adopted  for  the  relief  of  these 
various  complications  following  stricture  ? 

Retention  is  relieved  by  passage  of  the  catheter  and  withdrawal 
of  the  urine  if  this  measure  be  possible ;  by  aspiration  if  deemed 
expedient ;  and  by  the  operation  of  external  urethrotomy.  Cystitis 
of  the  neck  of  the  bladder  should  be  treated  by  rest,  remedies  to 
render  the  urine  alkaline  and  soothe  the  mucous  membrane,  such 
as  oil  of  sandalwood  and  fluid  extract  of  pechi.  In  selectino-  an 
alkali,  one  that  is  least  diuretic  should  be  given,  in  order  to  put  as 
little  work  as  possible  on  the  inflamed  bladder.  The  local  appli- 
cation of  a  few  drops  of  the  solution  of  nitrate  of  silver,  com- 
mencing with  1  and  increasing  to  3  grains  to  the  ounce,  can  be 
used  by  means  of  the  deep  urethral  syringe. 

Extravasation  of  urine  calls  for  immediate  operation  to  establish 
a  proper  drainage  from  the  bladder,  to  allow  the  escape  of  the  ex- 
travasated  urine,  and  to  prevent  the  occurrence  of  septicemia. 
Multiple  incisions  made  freely  through  the  entire  oedematous  tissue 
accomplishes  free  drainage  and  lessens  the  dangers  of  this  latter 
condition. 

Rupture  of  the  bladder  also  calls  for  rapid  operative  interfer- 
ence, and  is  probably  the  gravest  condition  which  occurs  as  a 
result  of  stricture. 

Epididymitis  is  not  generally  severe,  and  is  treated  the  same  as 
when  it  occurs  under  other  conditions. 


GENITO-UEINAEY    DISEASES— NON- 
VENEREAL. 

What  are  the  non-venereal  affections  of  the  genito-urinary  sys- 
tem? 

Diseases  of  the  penis,  scrotum,  and  adjacent  skin,  of  the  pros- 
tate, of  the  bladder,  kidneys,  and  ureters,  and  parasitic  aff'ections. 
These  are  considered  in  distinction  from  venereal  diseases,  since 
they  have  no  necessary  connection  with  sexual  intercourse  in  their 
origin. 

DIAGNOSIS. 

When  a  malady  exists  in  the  genito-urinary  apparatus,  what  ques- 
tions should  be  asked  in  order  to  determine  its  site  ? 
First,  in  regard  to  urination.     Is  it  frequent  or  not,  and  if  fre- 


76  GENITO-URINABY   DISEASES — NON- VENEREAL. 

quent  whether  relatively  greater  by  day  or  at  night  ?  Secondly, 
in  regard  to  pain.  Is  there  pain  in  the  genital  region,  and  if  so 
what  relation  does  it  bear  to  the  passage  of  urine — whether  during 
the  act,  following  it,  or  prior  to  ?  Thirdly,  the  character  of  the 
urine  as  it  appears  to  the  patient — whether  clear  or  containing  a 
deposit,  whether  it  contains  an  admixture  of  blood  apparently,  or 
whether  the  passage  of  blood  is  irrespective  of  the  urinary  flow  ? 

What  is  the  significance  of  the  various  signs  brought  out  by  the 
foregoing  questions? 

Frequency  of  urination  accompanies  urethritis  when  it  has  in- 
vaded or  is  entirely  located  in  the  deep  urethra,  being  due  to  a 
hyperaesthetic  condition  of  the  deep  canal.  It  also  accompanies 
common  cystitis,  the  bladder  being  unable  to  retain  urine  to  its  full 
capacity.  In  hypertrophy  of  the  prostate  the  frequent  micturition 
is  strangely  more  frequent  at  night  than  by  day,  while,  on  the  con- 
trary, when  there  exists  a  foreign  body  within  the  bladder,  such 
as  a  stone,  urination  is  more  frequent  by  day,  and  especially 
increases   with  exercise. 

The  Pain. — In  urethritis  and  prostatitis  it  is  felt  during  the 
urinary  act,  generally  at  the  end  of  the  penis,  and  in  prostatitis 
notably  also  at  the  end  of  the  act,  when  the  emptied  bladder  con- 
tracts down  on  the  inflamed  prostate.  In  cystitis  the  pain  is 
usually  felt  before  urination  from  the  distension  of  the  inflamed 
mucous  membrane,  which  pain  is  generally  felt  above  the  pubis. 
In  calculus  of  the  bladder  we  may  have  this  pain  before  urination 
as  a  result  of  the  accompanying  cystitis,  but  notably  the  pain  is  felt 
at  the  end  of  the  act  as  a  result  of  the  stone  being  brought  in  con- 
tact with  the  walls  of  the  emptied  bladder. 

In  Regard  to  the  Character  of  the  Urine. — If  it  contains  a  copious 
sediment,  its  nature  and  the  source  from  which  it  has  been  derived 
must  be  determined.  A  copious  deposit  of  pus  is  easily  recognized 
in  its  gross  appearance.  If  present  only  sufficiently  to  render  the 
urine  turbid,  a  small  quantity  of  such  a  specimen  shaken  up  with 
liquor  potassa  will  become  clear.  The  deposit  of  excessive  phos- 
phates or  urates  sometimes  misleads.  The  former  is  dissipated  by 
the  addition  of  an  acid,  and  the  latter  by  heat.  If  the  deposit  be 
pus  and  comes  entirely  from  the  urethra,  it  may  be  demonstrated 
by  passing  the  first  gush  of  urine  into  one  glass  and  the  remnant 
in  another.  The  first  specimen  will  contain  all  the  pus,  and  the 
second  will  be  transparent  and  apparently  normal.     If,  however,  it 


DIAGNOSIS.  77 

comes  from  the  bladder,  the  second  specimen  will  contain  equally 
as  large,  if  not  a  larger,  amount  of  free  pus,  which  will  eventually 
settle  down  in  the  bottom  of  a  glass.  When  the  greater  part  of 
the  pus  is  derived  from  the  kidney  as  the  result  of  pyelitis,  it  gener- 
ally settles  down  in  the  bottom  of  the  glass  in  a  clear-cut,  smooth- 
looking,  cup-shaped  mass,  leaving  the  urine  perfectly  clear.  Of 
course  the  best  and  most  accurate  means  of  determining  the  source 
of  pus  is  by  the  cystoscope.  These  gross  appearances  must  neces- 
sarily carry  only  trivial  weight,  but  may  at  times  be  useful,  com- 
bined with  other  signs,  in  arriving  at  a  diagnosis. 

Blood  in  the  urine  is  generall}'  regarded  as  of  serious  import,  but 
it  may  accompany  a  chronic  deep  urethral  inflammation,  when  it 
may  be  very  copious.  Blood  is  generally  a  more  or  less  constant 
symptom  of  tumors  in  the  bladder  and  of  stone,  sometimes  invari- 
ably present,  at  others  coming  in  irregular  gushes.  In  these  mala- 
dies it  is  always  increased  by  exercise. 

After  eliciting  from  the  patient  the  required  amount  of  information 
by  questioning,  what  is  the  next  means  to  resort  to  in  estab- 
lishing a  diagnosis,  and  how  is  it  conducted  ? 

Physical  Examination. — In  this  procedure  instruments  take  a 
very  important  part  in  the  role.  The  examination  for  stricture  has 
been  already  carefully  considered.  The  passage  of  a  steel  instru- 
ment into  the  bladder  in  chronic  prostatitis  will  reveal  a  hyper- 
sensitive state  in  this  region,  and  this,  coupled  with  frequent 
urination  and  the  absence  of  symptoms  indicating  cystitis,  together 
with  a  knowledge  of  the  causation  of  the  existing  trouble,  will 
establish  a  diagnosis.  In  patients  who  have  passed  the  age  of  fifty, 
where  the  possibility  of  a  hypertrophied  prostate  must  always  come 
up  for  consideration,  examination  per  rectum  will  reveal  the  con- 
dition of  the  prostate  gland,  and  the  passage  of  an  instrument  with 
a  short  beak,  such  as  the  Thompson  searcher,  discovers  the  presence 
of  a  prostatic  protrusion  or  a  prostatic  bar ;  and  in  this  condition, 
by  the  use  of  the  catheter,  the  presence  or  absence  of  residual  urine 
may  be  discovered,  as  well  as  the  demonstration  of  the  contractile 
power  of  the  bladder-walls.  Washing  of  the  bladder  and  examina- 
tion of  the  urine  immediately  after  this  manoeuvre  will  assist  in 
locating  a  trouble  higher  up  in  the  genito-urinary  apparatus.  The 
use  of  the  cystoscope  in  this  connection  is  of  great  value,  but 
requires  a  special  study  and  practice.  Palpation  of  the  abdomen, 
with  or  without  an  anaesthetic,  is  used  to  assist  in  detecting  tumors 


78  GENITO-URINARY   DISEASES — NON- VENEREAL. 

of  ttie  bladder-walls  and  of  the  kidneys ;  and  when  the  other 
symptoms  point  toward  a  stone  in  the  bladder,  its  presence  may 
be  demonstrated  by  the  use  of  the  proper  instrument  (Thompson's 
searcher). 

What  are  the  final  means  we  have  of  locating  a  malady  in  this 
region  ? 

Examination  chemically  and  microscopically  of  the  urine. 

What  is  the  proper  mode  of  proceeding  upon  this  examination  ? 

The  urine  should  always  be  received  in  two  separate  portions : 
the  first  and  smaller  part,  being  received  in  one  vessel,  represents 
the  washings  of  the  urethra.  The  second  portion  represents  the 
urine  as  it  comes  from  the  kidneys,  and  will  contain  whatever 
evidences  there  may  be  of  bladder  trouble.  This  second  specimen 
is  the  one  to  be  used  for  all  tests  except  where  the  trouble  exists 
in  the  urethra,  when  the  first  specimen  will  contain  the  elements 
of  importance  in  forming  a  diagnosis. 

The  examination  of  the  urine  other  than  by  inspection  in  an 
acute  urethritis  is  unimportant,  but  when  the  disease  is  situated  in 
the  deep  urethra  or  when  there  is  a  stricture  forming,  the  first 
specimen  will  reveal  characteristic  shreds  of  mucus  and  epithelia 
from  the  seat  of  the  malady. 

In  examining  the  specimens  of  urine  microscopically  in  order 
to  locate  a  lesion  in  the  genito-urinary  apparatus,  we  must  be 
acquainted  with  the  character  of  the  epithelium  of  its  various 
portions.  It  is  not  intended  here  to  give  a  detailed  description  of 
these  elements,  as  it  requires  a  careful  study  and  experience  to 
become  acquainted  with  them. 

In  order  to  use  the  microscope  with  any  degree  of  satisfaction  or 
value,  one  must  first  become  versed  in  locating  the  characteristic 
epithelia  of  the  different  regions,  so  that  when  a  given  specimen  is 
examined  these  epithelia  may  be  recognized  in  combination  with 
the  various  products  of  inflammation.  If  it  be  casually  stated  that 
from  the  prostatic  urethra  are  derived  round  and  oval  epithelia  of 
translucent  appearance,  and  from  the  bladder  columnar  epithelium 
of  different  degrees  of  texture,  and  from  the  pelvis  of  the  kidney 
caudate  epithelium,  such  a  description  will  be  only  misleading 
unless  it  serves  to  direct  the  student  or  practitioner  to  a  careful 
and  painstaking  study  of  the  subject. 

In  acute  cystitis  we  will  find  mostly  a  copious  amount  of  free 


DISEASES    OF   THE    PENIS.  79 

pus  combined  with  the  epithelial  elements  of  the  first  layer  of  the 
bladder. 

In  chronic  cystitis  we  find  combined  with  the  free  pus  the  ele- 
ments of  decomposition — deeper  epithelia  and  crystals  of  ammonio- 
magnesium  phosphates  ;  and  where  ulceration  exists,  this  will  also 
be  revealed  by  the  presence  of  blood  ;  but  blood  and  pus  also  come 
from  the  kidney,  and  it  is  only  by  an  interpretation  of  the  clinical 
history  and  other  general  signs,  together  with  the  attained  know- 
ledge of  the  various  epithelial  elements,  that  we  are  enabled  to 
arrive  at  an  accurate  diagnosis.  Cancer  elements  and  entozoa  are 
found  by  the  microscope  by  those  who  are  acquainted  with  them, 
as  well  as  tubercle  bacilli  when  properly  stained.  For  the  latter 
several  examinations  should  always  be  made,  as  their  absence  in 
one  or  two  specimens  is  only  negative  evidence,  they  being  very 
difficult  to  obtain. 

The  microscope  also  reveals  the  presence  of  spermatozoa  and  of 
the  crystals  of  uric  acid  and  oxalate  of  lime,  each  having  their 
special  significance.  Finally,  a  chemical  analysis  of  the  urine  is 
specially  important  to  determine  the  presence  or  absence  and 
quantity  of  albumin  or  sugar  and  other  abnormal  constituents,  as 
well  as  the  excess  of  the  normal  elements.  The  specific  gravity 
is  taken  to  determine  the  relative  quantity  of  solid  constituents, 
and  the  litmus  shows  its  normal  reaction  or  over-acidity  or  the 
reverse. 

DISEASES  OF  THE  PENIS  AND  ADJACENT 

PARTS. 

EPITHELIOMA  OP  THE  PENIS. 

Where  does  the  epithelioma  of  the  penis  most  frequently  first 
appear  ? 

It  usually  attacks  the  prepuce  and  spreads  to  the  glans,  although 
it  often  has  as  its  starting-site  the  latter  part,  especially  around  the 
meatus,  and  generally  appears  after  middle  life,  first  as  a  small  flat, 
warty  excrescence  or  an  excoriated  surface  with  a  slightly  indu- 
rated base. 

What  are  the  symptoms? 

The  surface  of  the  starting  sore,  if  it  has  not  already  become 
excoriated,  soon  takes  on  this  condition,  when  it  bleeds  a  little  and 
is  the  seat  of  darting  pains  or  burning  sensations.     A  scab  soon 


80  DISEASES   OF   THE   PENIS. 

forms  over  the  exposed  spot,  which  is  dark-colored,  and  if  it  be 
picked  or  falls  off,  reveals  an  ulcerating  surface.  Other  scabs 
form  and  fall  off,  and  thus  the  ulceration  extends  backward,  invad- 
ing all  tissue  within  its  course.  The  discharge  it  emits  is  thin, 
blood-stained,  and  foetid.  The  ulcer  which  it  forms  is  irregularly 
deep  and  unhealthy  in  appearance,  with  indurated,  unhealthy, 
everted  edges.  Its  course,  if  slow  at  first,  progressively  increases 
in  rapidity,  and  the  disease  commences  to  vent  itself  upon  the  health 
and  strength  of  the  individual.  The  inguinal  glands  on  both  sides 
enlarge,  becoming  involved,  and  also  ulcerate.  If  the  strength  of 
the  patient  holds  out,  there  is  no  limit  to  the  area  over  which  this 
dire  disease  may  extend.  It  may  involve  the  entire  external  geni- 
tals, causing  their  destruction  and  perhaps  total  loss,  and  spread 
down  the  thighs  and  over  the  abdomen.  In  this  extreme  condition 
the  patient  may  die  of  hemorrhage,  some  large  vessel  being  opened 
by  the  ulceration. 

The  diagnosis  of  this  disease  should  not  be  a  difficult  one.  If 
it  commences  as  a  warty  growth,  it  is  difficult  to  decide  until  ulce- 
ration has  set  in,  and  warty  growths  of  a  flattened  appearance  occur- 
ring after  middle  life  and  in  cleanly  subjects  should  always  excite 
suspicion.  After  ulceration  has  well  set  in  and  started  on  its  course, 
the  nature  of  the  disease  is  at  once  revealed,  and  radical  means  for 
its  removal  should  immediately  suggest  themselves.  In  fact,  the 
only  good  chance  for  recovery  is  in  attacking  the  disease  early,  before 
it  has  spread  to  the  inguinal  glands,  and  complete  removal  of  the 
affected  area  accomplished.  If  it  be  slight,  extensive  scraping  and 
cauterization  may  effect  a  cure,  but  where  a  great  deal  of  tissue 
is  involved  no  halfway  measures  should  be  adopted.  Complete 
removal,  well  up  into  the  healthy  tissue,  is  the  only  hope  to  hold 
out.  Should  the  inguinal  glands  become  involved,  they  also  should 
be  removed  thoroughly  at  the  same  time,  and  even  such  removal 
holds  forth  only  a  slender  hope  of  permanent  cure.  Cancer  of  the 
penis  in  other  forms  than  the  above-described  epithelial  variety  is 
very  rare. 


BALANITIS  AND  POSTHITIS. 

What  is  balanitis? 

Inflammation  of  the  mucous  membrane  surrounding  the  glans 
penis. 


BALANITIS   AND   POSTHITIS.  81 

What  is  inflammation  of  the  prepuce  called  ? 

Posthitis. 

Do  these  two  troubles  generally  accompany  each  other? 

Yes. 

What  is  the  cause  of  their  existence  ? 

A  long  and  tight  prepuce  accompanied  by  uncleanliness,  retention 
of  the  sebaceous  discharges,  or  prolonged  contact  with  gonorrhceal 
pus  are  the  exciting  causes,  added  to  which  there  is  a  predisposition 
which  some  individuals  possess  to  this  condition  of  inflammation  of 
the  mucous  membrane  around  the  glans  penis. 

What  are  the  symptoms  of  this  malady  ? 

First,  redness  of  the  mucous  membrane,  which  is  soon  accompa- 
nied by  a  disagreeable  discharge  and  infiltration  of  the  surrounding 
parts.  These  become  sensitive  on  manipulation,  and  are  accompa- 
nied by  a  burning  pain  during  any  exertion.  Sometimes  ulcerations 
are  produced,  which  may  be  confounded  with  chancroid  or  herpetic 
eruptions. 

What  is  the  nature  of  these  ulcerations  when  they  appear  ? 

They  are  rarely  deep,  and  simply  appear  as  irregular  excoriations. 
They  may  be  accompanied  by  a  free  purulent  discharge,  but  have 
not  the  symptoms  of  chancroid  which  have  already  been  mentioned. 

May  they  be  accompanied  by  enlargement  of  the  inguinal  glands  ? 

The  glands  sometimes  become  large  and  tender,  but  they  rarely 
suppurate  in  this  condition. 

What  other  complications  may  accompany  balanitis? 

Warty  growths  sometimes  appear,  the  condition  being  those  that 
favor  their  development.  Phimosis  may  be  produced,  which  also 
may  lead  to  paraphimosis. 

What  is  the  treatment? 

Cleanliness  is  the  first  and  most  important  item  in  the  treatment 
of  this  malady.  Warm  water  without  soap  should  be  resorted  to, 
and  then  the  parts  dusted  with  a  mild  and  unirritating  powder,  such 
as  calomel  or  calcined  magnesia,  iodoform  or  aristol.  This  simple 
method,  frequently  resorted  to  during  the  day,  will  often  efi'ect  a 
cure.     Other  modes  of  treatment  are  found  in  the  astringent  and 

6— G-U. 


82 


DISEASES   OF   THE   PENIS. 


soothing  lotions,  sucli  as  spirits  of  wine  and  water  1  part  to  4,  the 
officinal  lead-and-opium  wash,  or  the  following  lotion : 

R.  Aluminis,  1 ; 

Plumbi  subacetat.,        5 ; 
Aquae,  500. 

What  conditions  accompanying  inflammation  of  the  prepuce  in- 
tensify the  malady? 
A  long  foreskin  and  phimosis. 

PHIMOSIS   AND  PARAPHIMOSIS. 

What  is  phimosis? 

Phimosis  is  contraction  of  the  natural  orifice  of  the  prepuce, 
which  condition  may  be  congenital  or  acquired. 

How  may  it  be  acquired? 

By  injuries,  burns,  etc.,  and  inflammation  (balanitis),  which  tend 
to  narrow  further  by  swelling  a  perhaps  naturally  small  orifice. 
The  inflammation  may  be  the  result  of  an  existing  chancre  or 
chancroid. 

What  is  paraphimosis  ? 

Paraphimosis  is  where  a  tight  prepuce  in  an  inflammatory  condi- 
tion is  retained  behind  the  corona  glandis  by  an  increased  swelling, 
which  prevents  its  release,  and  thus  presents  the  appearance  of  a 
tight  band  around  the  mucous  membrane  behind  the  corona. 

What  is  the  treatment  of  balanitis  and  phimosis  ? 

Phimosis  may  be  the  cause  of  balanitis  by  being  a  continual 
source  of  irritation  to  the  glans  penis,  and  therefore  its  removal 

Fig.  8. 


Taylor's  Duck-bill  Syringe. 

may  prevent  a  continual  tendency  to  this  condition.  On  the  other 
hand,  balanitis  may  cause  phimosis,  and  its  cure  also  will  relieve 
this  condition  and  may  also  prevent  a  possible  paraphimosis. 
The  treatment  of  uncomplicated  balanitis  has  already  been  given. 


PHIMOSIS   AND   PARAPHIMOSIS.  83 

(The  accompanying  cut  shows  a  flat-nozzled  syringe  used  for  appli- 
cations between  glans  and  prepuce.)  Phimosis,  which  has  often 
as  its  cause  a  balanitis,  may  be  cured  only  temporarily  by  the 
method  of  treatment  which  is  used  for  the  latter,  and  is  apt  to 
return  upon  slight  cause.  If  a  chancre  or  chancroid  exists  within 
the  foreskin,  the  treatment  must  be  expectant  and  cleansing.  It  is 
difficult  to  decide  with  certainty  the  nature  of  a  sore  under  these 
conditions,  and  incision  must  be  a  dernier  resort.  Astringent  and 
alterative  applications  can  be  made  by  the  use  of  the  "  duck-bill " 
syringe  (Fig.  8)  with  usual  benefit.  If  by  the  induration  and  con- 
dition of  the  inguinal  glans  a  chancre  is  decided  upon,  the  use  of 
a  mild  solution  of  oleate  of  mercury  (5  per  cent.)  may  benefit. 

What  is  the  radical  means  of  curing  phimosis  ? 

Circumcision. 

What  does  this  mean? 

Removal  of  the  foreskin. 

How  is  this  practised  in  surgery  ? 

The  amount  of  foreskin  decided  to  be  removed  is  first  nipped 
ofi"  by  the  scissors  or  knife,  and  the  "  mucous  membrane,"  after  being 
trimmed  down  close  to  the  corona,  is  sewed  to  the  freshly-cut  edges 
X)f  the  skin  by  interrupted  sutures  of  horsehair  or  catgut.  If 
after  removing  the  portion  of  the  foreskin  the  opening  is  found  to 
be  still  tight  for  the  glans,  the  mucous  membrane  may  be  slit  verti- 
cally on  either  side  ;  and  when  the  mucous  membrane  is  trimmed, 
a  triangular-shaped  flap  is  left  on  both  sides  to  fit  in  and  enlarge 
the  opening  of  the  foreskin. 

How  is  paraphimosis  relieved? 

Sometimes  by  soaking  the  inflamed  organ  in  a  vessel  containing 
water  as  hot  as  can  be  borne  will  suffice  to  partially  allay  the 
swelling  and  permit  the  inflamed  skin  to  be  rolled  over  the  glans 
penis.  If  this  cannot  be  effected,  a  strip  of  bandage,  rubber,  or 
muslin,  applied  first  uniformly  over  the  glans  penis  very  tightly, 
and  then  over  the  rest  of  the  penis,  so  as  to  force  out  the  contained 
blood  in  the  veins  of  the  organ,  then  quickly  released,  may  allow 
the  passage  of  the  foreskin  beyond  its  obstruction.  If  this  cannot 
be  accomplished  by  such  means,  incision  must  be  resorted  to. 

What  are  the  objections  to  this  latter  procedure  ? 

Sometimes  the  inflammation  which  produces  the  paraphimosis  is 


84  DISEASES   OF   THE   PENIS. 

due  to  a  chancroid.     An  incision  would  naturally  allow  an  infection 
of  the  newly-denuded  area. 

If,  however,  the  constricted  portion  be  so  great  as  to  endanger 
the  loss  of  a  large  amount  of  tissue  from  sloughing,  and  in- 
cision is  inevitable,  chancroid  being  present,  what  means 
should  we  resort  to  to  guard  against  an  extension  of  the 
chancroidal  ulceration? 

Free  and  copious  cauterization  of  the  cut  edges  by  the  use  of 
fuming  nitric  acid. 

HERPES  PROGENITALIS. 
What  is  herpes  progenitalis  ? 

It  consists  of  an  accumulation  of"  vesicles,  resembling  in  their 
character  herpes  of  other  portions  of  the  body,  situated  on  the 
mucous  membrane  of  the  glans  and  the  prepuce,  often  involving 
the  adjacent  skin. 

What  symptoms  accompany  these  vesicles  ?  and  what  is  their 
cause  ? 

They  are  accompanied  by  a  slight  burning  sensation  and  itching. 
Those  upon  the  skin  remain  as  vesicles,  and  as  vesicles  run  a  course 
similar  to  herpes  on  other  integumentary  portions  of  the  body ; 
but  those  situated  upon  the  mucous  membrane  within  the  prepuce 
become  flattened  down  from  rupture,  and  present  more  the  ap- 
pearance of  small  and  multiple  ulcerations.  Under  these  circum- 
stances they  are  more  apt  to  produce  secondary  inflammation  of 
the  surrounding  parts,  and  lead-  to  the  same  complications  which 
accompany  balanitis. 

What  is  the  treatment  of  these  lesions  ? 

Proper  attention  to  cleanliness  of  the  parts  is  the  essential  fea- 
ture, and  astringent  lotions,  or  preferably  powders,  such  as  calomel 
or  bismuth,  are  a  proper  means  of  medicinal  treatment. 

Are  they  ever  complicated  with  swelling  of  the  inguinal  glands  ? 

They  are  quite  apt  to  be  attended  by  tenderness  in  this  region, 
and  liable  under  the  same  conditions  which  would  encourage  sup- 
puration elsewhere  to  result  in  abscess  ;  that  is  to  say,  a  condition 
of  ill-health  and  poor  nourishment  of  the  body. 

With  what  may  these  herpetic  lesions  be  confounded  in  diagnosis  ? 

Chancroid  and  balanitis  with  ulcerated  spots. 


CUTANEOUS  AFFECTIONS. 


85 


What  are  the  distinguishing  points  in  their  differential  diagnosis  ? 

In  their  early  career,  when  they  appear  as  vesicles,  the  diagnosis 
is  not  difficult.  When  they  become  flattened  and  more  or  less 
ulcerated,  the  fact  that  they  have  formerly  appeared  as  vesicles  is 
a  distinguishing  point  in  diagnosing  them.  Balanitis  comes  on 
after  the  vesicles  have  appeared  in  the  case  of  its  accompanying 
herpes,  whereas  it  precedes  the  appearance  of  any  ulcerated  spots 
which  may  occur  during  its  course. 

What  is  the  nature  of  the  discharge  of  these  broken-down  her- 
petic clusters? 
It  varies  according  to  the  amount  of  inflammation   surrounding 
them.     It  may  be  sero-purulent,  or  even  purulent  under  irritation. 

What  is  the  distinguishing  feature  between  this  discharge  and 
that  of  chancroidal  pus  ? 
It  is  not  auto-inoculable.     If  inoculated  in  another  portion  of 
the  body  it  will  not  produce  similar  lesions. 


CUTANEOUS  AFFECTIONS. 

PEDICULOSIS  PUBIS. 

What  parasitic  disease  frequently  attacks  the  external  genitals? 

Pediculi  pubis. 

How  is  this  malady  generally  ac-  Fig.  9. 

quired  ? 

By  contact  with  the  same  dis- 
ease in  another  person,  or  by  ac- 
quiring the  parasites  from  a  water- 
closet. 

What  does  the  disease  consist  of? 

The  presence  around  the  genital 
organs  of  certain  parasites  or  pedi- 
culi, which  are  generally  found 
upon  the  scrotum  and  upper  por- 
tion of  the  thighs  or  any  portion 
of  the  body  where  the  hairs  of 
puberty  occur. 

In  what  manner  does  this  disease 
show  itself? 
The  only  symptoms  are  the  itching  and  lesions  caused  by  the 


Pediculi  Pubis. 


86  THE  PROSTATE   GLAND. 

bite  of  tlie  insects,  and  the  diagnosis  of  the  disease  is  established 
only  by  the  discovery  of  the  pediculi. 

What  treatment  is  to  be  pursued  for  the  removal  of  these  parasites  ? 
The  old-fashioned  blue  ointment,  rubbed  freely  into  the  hairs  of 
the  mons  veneris  and  around  the  regions  of  the  scrotum  and  upper 
thighs,  is  the  most  eifective  treatment.  The  insects  may  also  be 
destroyed  by  sprinkling  the  parts  with  calomel  or  applying  a  strong 
lotion  of  corrosive  sublimate. 

THE  PROSTATE  GLAND. 

What  is  the  prostate  gland? 

A  small  glandular  body,  consisting  mostly  of  muscular  tissue, 
surrounding  the  neck  of  the  bladder  and  the  first  inch  of  the 
urethra.  It  contains  mucous  glands  which  open  on  the  floor  of 
the  urethra,  and  is  pierced  by  the  two  ejaculatory  ducts,  each  of 
which  is  made  by  the  union  of  the  vas  deferens  with  the  duct  of 
the  seminal  vesicle  on  the  same  side.  The  prostate  is  covered  by 
a  fibrous  capsule.  The  pelvic  fascia  or  posterior  layer  of  the 
triangular  ligament  holds  it  in  place,  together  with  the  pubo-pros- 
tatic  ligaments.  It  is  composed  of  two  lateral  lobes  which  form 
one  symmetrical  body. 

What  is  the  function  of  the  prostate  ? 

Its  main  function  is  as  a  muscular  organ  to  contract  and  expel 
the  semen  after  it  has  collected  in  the  prostatic  sinus,  which  act  is 
a  part  of  the  venereal  orgasm. 

What  is  that  morbid  condition  which  the  prostate  is  most  liable  to, 
and  which  most  commonly  appears  before  the  physician  ? 

Hypertrophy,  either  general  or  partial  or  circumscribed.  The 
cause  of  hypertrophy  of  the  prostate  is  not  known. 

What  is  the  size  and  shape  of  the  prostate  under  this  morbid  con- 
dition ? 

No  definite  limit  to  the  size  can  be  named,  and  it  may  take 
almost  any  shape,  depending  upon  the  part  involved.  It  may  be 
smooth  and  round  or  unsymmetrical  and  nodular.  The  portion 
most  frequently  involved  in  hypertrophy  is  the  posterior  median 
part  known  as  the  '•  third  lobe,"  which  latter  is  a  pathological  con- 
dition, and  consists  of  a  growth  of  the  prostate  between  the  two 
ejaculatory  ducts,  and  may  be,  perhaps,  due  to  the  absence  of 


ANATOMY   Al^D   PHYSIOLOGY.  87 

capsule  here.  It  is  usually  an  oval  or  rounded  tumor  wliich  juts 
out  posteriorly  into  the  cavity  of  the  bladder.  When  the  hyper- 
trophy proceeds  laterally,  it  may  affect  one  or  both  sides,  and  when 
both  are  affected  the  outgrowth  in  the  middle  partially  fills  up  the 
orifice  of  the  urethra,  leaving  only  a  small  passage  on  either  side, 
and  the  mucous  membrane  is  often  drawn  up  at  these  points,  form- 
ing a  "  bar  "  at  the  neck  of  the  bladder.  Imbedded  in  this  mass  it 
is  common  to  find  small  nodular  tumors,  easily  enucleated,  from 
the  size  of  a  pea  to  a  marble.  Hypertrophy  of  the  prostate  may 
assume  various  other  formations. 

What  varieties  of  prostatic  "  bar  "  exist  in  these  cases  ? 

(1)  Where  there  is  a  transverse  bar  or  wall  of  hypertrophied 
tissue  instead  of  the  usual  rounded  tumor ;  (2)  the  elevated  folds 
of  mucous  membrane  between  the  lateral  lobes  or  between  them 
and  the  so-called  third  lobe ;  (3)  a  bar  formed  by  the  hypertrophy 
of  the  bladder  tissue  just  behind  the  prostate,  seated  in  the  mus- 
cular fibres  which  run  across  the  trigona  vesica.  This  latter  bar 
may  produce  an  obstruction  which  is  totally  distinct  from  any 
prostatic  outgrowth. 

What  are  the  symptoms  of  enlarged  prostate  ? 

The  symptoms  of  enlarged  prostate  are,  like  stricture,  the  symp- 
toms which  occur  from  mechanical  obstruction.  These  symptoms 
are  derived  especially  from  the  part  which  suffers  most  as  a  result 
of  the  obstruction — namely,  the  bladder. 

What  is  the  effect  of  hypertrophy  upon  the  prostatic  urethra  as 
regards  its  normal  dimensions? 

As  the  prostate  enlarges  in  its  vertical  diameter  the  urethra 
elongates  at  the  same  time.  Its  course  may  be  affected,  and 
become  even  tortuous,  and  its  calibre  diminished.  There  may  be 
a  considerable  amount  of  hypertrophy,  involving  only  slightly  the 
prostatic  urethra,  or  a  small  amount  of  hypertrophy,  with  a  large 
obliteration  of  the  canal,  posterior  median  hypertrophy,  which  com- 
prises a  majority  of  cases  which  come  under  observation.  Unless 
an  enlarged  prostate  develops  as  this  median  hypertrophy,  pro- 
ducing an  obstruction  to  the  passage  of  urine,  there  is  apt  to  be 
no  symptoms  which  may  call  the  condition  to  the  mind  of  the 
individual,  as  there  happens  to  be  no  source  of  discomfort  for 
which  to  seek  relief. 


88  THE   PROSTATE   GLAND. 

What  is  the  most  prominent  symptom  in  the  distressing  form 
of  hypertrophied  prostate  ? 

Retention. 

How  is  this  determined? 

By  the  urgent  desire  of  the  patient  to  pass  water,  the  history 
of  a  long  interval  since  the  last  act  being  given,  and  the  appear- 
ance of  the  over-distended  bladder  above  the  pubis,  the  outline  of 
which  may  be  mapped  out  by  percussion. 

How  is  this  condition  relieved  ? 

By  the  introduction  of  a  proper  catheter  for  the  withdrawal  of 
the  urine. 

Is  there  any  difference  in  the  kind  of  instrument  which  should 
be  used  imder  such  conditions? 

An  instrument  of  the  ordinary  curve  must  strike  against  the 
obstructing  prostate  and  refuse  to  enter  the  bladder.  Steel  instru- 
ments are  made  with  the  proper  curve,  which  curve  should  be  bent 
so  as  to  be  exaggerated,  and  its  last  inch  show  a  more  decided  turn 
than  the  rest.  The  hard-rubber  English  catheter  may  be  used,  and 
if  desired  it  may  contain  a  stylet,  so  that  any  curve  given  to  it 
will  remain.  The  Mercier  instruments  are  exceedingly  useful  in 
these  conditions,  and  are  made  with  a  slight  turn,  about  half  an 
inch  from  the  end,  which  gives  them  the  tendency  to  ride  over  any 
obstruction  in  the  prostatic  region.  There  are  few  cases  of  pros- 
tatic obstruction  accompanied  by  retention  which  cannot  be  relieved 
by  experienced  hands  with  the  proper  instruments ;  but  an  occa- 
sional case  occurs  where  the  obstruction  seems  to  be  impassable, 
and  aspiration  of  the  bladder  becomes  necessary,  or  perhaps  con- 
tinual drainage  over  the  pubis. 

What  are  the  first  symptoms  which  announce  the  presence  of 
an  obstructing  enlarged  prostate? 

Frequent  urination :  the  patient  generally  complains  of  rising 
once  or  twice  during  the  night ;  pain  in  urinating,  which  occurs 
at  the  end  of  the  urinary  act  and  is  felt  at  the  tip  of  the  penis. 

What  is  the  condition  of  the  urine  which  is  voided  during  this 
condition  ? 

It  depends  upon  the  extent  of  the  obstruction  and  the  length 
of  time  it  has  existed. 


ENLARGEMENT,   SYMPTOMS.  89 

What  eflfect  does  the  obstructing  prostate  have  upon  the  bladder 
itself? 

By  continually  causing  it  to  overstrain  in  its  attempts  to  over- 
come the  obstruction  it  necessarily  becomes  weakened,  and  grad- 
ually develops  atony.  As  a  result  of  this  weakness  there  exists  a 
certain  amount  of  retained  or  residual  urine  in  the  bladder,  which, 
undergoing  decomposition,  causes  a  cystitis  and  is  voided  in  a  foul, 
ammoniacal  state. 

How  is  the  existence  of  residual  urine  determined  ? 

By  asking  the  patient  to  pass  all  the  urine  possible,  and  then 
by  introducing  a  catheter  an  amount  of  residual  urine  may  be 
removed. 

What  other  condition  shows  itself  in  the  early  career  of  an  en- 
larged prostate? 

Urinary  overflow.  Distension  of  the  bladder,  caused  by  the  ob- 
struction, forces  through  the  narrow  orifice  a  small  amount  of  the 
retained  urine,  which  condition  is  called  overflow,  and  must  not  be 
confounded,  as  it  sometimes  is,  with  incontinence,  which  is  really  a 
lack  of  power  to  retain  the  urine. 

What  precautions  should  be  used  in  the  first  examination  of 
patients  suflFering  from  an  enlarged  prostate? 

The  patient  should  be  questioned  in  regard  to  a  previous  ex- 
amination as  to  the  effect  instrumentation  produces,  and  the  same 
care  should  be  used  here  as  in  the  examination  for  stricture.  If 
after  a  patient  has  passed  his  urine  a  catheter  be  introduced  for  the 
purpose  of  determining  the  amount  of  residual  urine,  and  it  be 
found,  the  entire  quantity  should  not  be  removed  unless  a  small 
amount  of  a  disinfecting  solution  be  introduced  to  replace  it,  as  the 
liability  to  urethral  fever  is  just  as  characteristic  from  such  a  pro- 
cedure as  in  cases  of  stricture  after  examination. 

How  do  we  proceed  to  enter  the  bladder  in  prostatic  cases? 

The  proper  instrument  should  be  selected,  and  one  especially 
adaptable  to  a  given  case  cannot  be  discovered  without  trial.  As 
a  rule,  the  Mercier  catheters  are  suitable  for  these  cases,  and  the 
little  bend  at  the  small  end  serves  to  override  the  prostatic  obstruc- 
tion. If  this  fails,  select  a  small-sized  English  catheter  and  with 
the  stylet  bend  it  so  as  to  give  it  the  characteristic  prostatic  long 
curve. 


90  THE   PROSTATE   GLAND. 

How  do  we  estimate  the  character  and  extent  of  a  prostatic 
hypertrophy  ? 

Introduce  a  silver  catheter  with  a  prostatic  curve,  and  if  the 
urethra  be  deviated  to  either  side  a  corresponding  deviation  of  the 
point  of  the  instrument  may  be  felt  on  its  introduction.  The 
elongation  of  the  prostatic  urethra  may  be  roughly  determined  by 
marking  the  depth  to  which  the  instrument  has  to  be  introduced 
before  the  urine  flows.  Instead  of  the  natural  7  or  8  inches,  it 
may  perhaps  be  from  10  to  12  niches.  To  map  out  the  con- 
tour of  the  growth  around  the  neck  of  the  bladder  a  Thompson's 
searcher,  such  as  is  used  for  exploring  the  bladder  for  stone,  will 
render  the  necessary  amount  of  information.  (The  accompanying 
illustration  (Fig.  10)  shows  Thompson's  instrument.)      In  intro- 

FiG.  10. 


Thompson's  Searcher. 

ducing  this  instrument  it  is  necessary  to  depress  the  handle  mark- 
edly, so  as  to  introduce  it  through  the  last  part  of  the  prostatic 
urethra,  in  order  to  make  it  ride  over  the  median  enlargement.  If 
the  beak  of  the  instrument  seems  to  strike  emphatically  against  an 
elevation  or  to  slip  with  a  sudden  start  over  a  mound,  it  is  probably 
the  prostatic  "  bar."  When  the  beak  is  fairly  in  the  bladder  the 
instrument  can  be  held  horizontally  if  the  prostate  is  healthy  or  if 
only  a  bar  exists,  and  rotation  of  the  instrument  can  be  eiFected  with- 
out deviating  the  direction  of  the  shaft ;  but  if  there  be  any  ob- 
struction inside  of  the  bladder,  such  as  a  jutting  tumor  from  the 
prostate,  the  direction  of  the  shaft  must  be  deviated  to  allow  the  in- 
strument to  pass  over  this  obstacle,  and  thus  the  position  of  the 
growth  may  be  determined.  In  the  case  of  a  healthy  prostate  the 
instrument  may  be  withdrawn  with  its  point  turned  down,  but  in 
the  case  of  the  median  enlargement  the  instrument  will  hook 
against  the  impending  lobe.  By  this  instrument  the  character  of 
the  texture  of  the  walls  of  the  bladder  may  also  be  investigated, 
and  by  carefully  exploring  the  bladder  systematically  on  one  side 
and  then  on  the  other  by  a  rotatory  movement  of  the  sound,  the 
presence  or  absence  of  a  stone  may  be  determined. 


ENLARGEMENT TREATMENT.  91 

What  is  the  course  of  treatment  to  pursue  in  cases  of  enlarged 
prostate  which  require  attention? 

There  is  no  medicine  or  application  known  which  can  be  said  to 
cure  this  condition.  Simple  inflammatory  enlargement  may  be  suc- 
cessfully alleviated  by  the  same  means  of  counter-irritation  and  pres- 
sure which  have  formerly  been  used.  The  specific  treatment  for  the 
enlarged  prostate  is  the  use  of  the  catheter,  and  while  by  this  means 
a  cure  of  the  condition  need  never  be  hoped  for,  it  being  a  mechanical 
obstruction,  yet  there  is  hardly  any  limit  to  the  comfort  which  may 
be  given  by  its  proper  use,  the  subjective  symptoms  being  almost 
entirely  removed.  It  is  well  to  commence  the  course  of  treatment 
of  a  prostatic  hypertrophy  by  blunting  the  sensibility  of  the  deep 
urethra  by  the  passage  of  a  steel  sound  or  rubber  bougie  at  proper 
intervals,  endeavoring  to  overcome  the  muscular  spasm  to  which 
most  of  the  symptoms  are  due.  A  great  deal  of  satisfaction  is 
found  in  combating  prostatic  irritability  and  inflammation  of  the 
neck  of  the  bladder  by  the  use  of  nitrate-of-silver  injections  by 
means  of  a  deep  urethral  syringe  (shown  in  a  previous  illustra- 
tion), throwing  in  the  membranous  urethra  several  minims  of  the 
solution  of  nitrate  of  silver,  beginning  with  i  grain  to  the  ounce 
and  running  it  up  to  10  or  15,  commencing  with  an  interval  of  two 
or  three  days,  increasing  the  interval  as  you  increase  the  strength  of 
the  solution.  This  finds  its  proper  use  in  certain  cases,  while  some 
do  not  respond  to  it.  Where  there  is  a  small  amount  of  residual 
urine  and  no  cystitis  the  catheter  has  small  value  ;  but  where  Na- 
ture lacks  the  ability  to  carry  out  this  function  of  emptying  the 
bladder,  the  assistance  which  the  catheter  afibrds  under  these  cir- 
cumstances is  indispensable  ;  but  too  much  care  cannot  be  taken 
in  introducing  the  patient  to  the  habitual  use  of  the  catheter.  A 
great  deal  of  danger  accompanies  this  procedure,  unless  it  be  pur- 
sued with  a  delicacy  that  is  hard  to  teach  those  who  have  not  had 
an  unfortunate  case  which  has  resulted  from  a  lack  of  proper  care. 
After  the  first  test  for  residual  urine,  as  previously  described,  the 
patient  should  remain  quiet  for  several  hours,  and  preferably  for  a 
day,  and  after  a  few  days  the  same  process  may  be  repeated  ;  and 
if  the  symptoms  do  not  contraindicate  it  the  bladder  may  be  entirely 
emptied  and  left  empty.  The  most  common  form  of  catheter  fever 
which  comes  on  in  these  cases  happens  four  or  five  days  or  so  after 
the  first  introduction,  evidenced  by  a  chill  and  general  feeling  of 
malaise,  the  urine  being  heavy  and  foggy  from  the  existence  of 
mucus  and  pus. 


92  THE   PROSTATE   GLAND. 

After  the  surgeon  has  settled  upon  a  proper  instrument  and  got- 
ten the  bladder  in  a  state  of  tolerance,  and  perhaps  carried  the 
patient  through  a  fever  or  cystitis,  the  next  course  is  to  properly 
instruct  the  patient  himself  in  the  use  of  his  instrument,  impress- 
ing upon  him  firmly  the  fact  that  it  will  be  necessary  for  him  to 
care  for  himself  in  this  way  for  the  rest  of  his  life.  The  warmth 
of  his  body  must  be  carefully  looked  to,  giving  special  attention  to 
those  more  or  less  exposed  portions,  such  as  the  feet  and  ankles. 
There  is  no  necessity  for  a  change  of  diet  in  ordinary  cases.  Exer- 
cise is  good,  and  as  a  general  rule  the  catheter  should  be  used  ac- 
cording to  the  amount  of  residual  urine  and  corresponding  to  the 
regular  intervals  of  normal  urination.  In  ordinary  cases,  where 
the  increased  desire  to  urinate  is  mainly  at  night,  the  emptying  of  the 
bladder  before  retiring  may  be  all  that  is  required  until  early  morn- 
ing, when  the  process  can  be  repeated.  Where  there  is  a  large 
amount  of  residual  urine  it  is  better  for  the  patient  to  rely  en- 
tirely upon  the  catheter  and  pass  it  at  frequent  intervals,  without 
attempting  to  urinate  at  all.  This  treatment  may  place  a  patient 
in  a  comfortable  position,  and  he  may  live  for  years  with  a  great 
deal  of  comfort  and  satisfaction.  In  cases  where  there  is  con- 
siderable atony  the  washing  of  the  bladder  by  means  of  a  warm 
solution  of  boracic  acid,  about  3  per  cent,  or  more,  is  necessary  to 
destroy  the  formation  of  a  stone  and  a  pos.sible  inflammation  incurred 
by  the  decomposing  urine.  The  number  of  washings  to  be  employed 
is  determined  by  the  condition  of  the  urine.  The  patient  should 
be  carefully  instructed  both  in  the  proper  passage  of  a  catheter  and 
in  the  process  of  properly  washing  the  bladder.  There  is  always  a 
danger  during  the  course  of  these  cases  of  a  cystitis  lighting  up  from 
the  effect  of  cold  or  irritating  urine.  This  may  result  in  retention 
of  the  urine,  when  it  will  become  quite  necessary  for  the  patient  to 
be  able  to  introduce  a  catheter. 

Supposing  retention  of  urine  occurs  and  repeated  attempts  to 
introduce  the  catheter  fail,  what  course  can  be  pursued  ? 

The  aspirator  should  be  used  twicc'daily  above  the  pubis,  and  in 
the  interim  repeated  attempts  may  be  made  to  introduce  the  cath- 
eter. If  all  efforts  finally  fail,  a  permanent  opening  may  be 
made  above  the  pubis  and  a  canula  be  employed.  But  if  cath- 
eterization and  aspiration  both  fail,  it  would  seem  best  to  delay 
measures  and  quiet  the  patient  with  anodynes  until  preparations 
have  been  made  for  a  radical  operation. 


ENLARGEMENT COMPLICATIONS.  93 

What  is  the  proper  manner  of  washing  out  a  bladder  ? 

After  the  residual  urine  has  been  withdrawn  by  means  of  the 
same  catheter  employed  for  this  purpose,  a  warm  boracic  solution  is 
introduced  into  the  bladder  with  a  bulbed  syringe,  which  is  most 
manageable  in  the  hands  of  the  surgeon,  distending  the  bladder 
with  the  fluid  up  to  its  full  capacity  or  to  the  amount  that  the 
patient  can  comfortably  hold,  and  then  allowing  the  same  to  pass 
out.  The  process  is  continued  until  the  returned  fluid  becomes  clean. 
For  the  patient's  use  the  best  washing  apparatus  is  an  ordinary 
fountain  syringe,  with  a  "  two-way  "  metallic  stopcock  attached  (the 
Van  Buren  and  Keyes'  bladder-washer),  the  mechanism  of  which  is 
to  force  the  fluid  into  the  bladder,  freely  distending  it ;  after 
which  by  a  turn  of  the  stopcock  it  returns  through  the  catheter 
and  out  of  the  side  arm  of  the  stopcock.  Boracic-acid  solution  is 
most  commonly  used  for  bladder-washing,  but  where  a  mild  cys- 
titis seems  to  increase  and  the  secretion  of  pus  becomes  greater,  it 
is  well  to  change  this  injection  to  that  of  dilute  nitric  acid,  diluted 
20  minims  to  the  pint,  or,  better,  nitrate  of  silver  1  to  5  grains  to 
the  pint,  or  stronger  if  it  can  be  endured. 

What  are  the  complications  which  are  liable  to  occur  in  the  early 
stage  of  hypertrophied  prostate  ? 

One  or  both  testicles  may  enlarge.  This  is  not  a  serious  con- 
dition, and  may  be  relieved  by  the  ordinary  methods.  The  intro- 
duction of  the  catheter  can  be  continued.  The  swelling  generally 
subsides  under  rational  treatment.  The  most  troublesome  compli- 
cation liable  to  occur  during  the  treatment  of  these  cases  is  con- 
gestion of  the  neck  of  the  bladder,  which  is  apt  to  lead  up  to 
cystitis.  The  latter  announces  itself  by  a  diminished  capacity  of 
the  bladder  to  contain  fluid,  increased  amount  of  pus,  and  generally 
by  the  presence  of  blood  in  the  urine.  This  cystitis  is  more  apt  to 
light  up  in  recent  cases  or  those  in  which  the  treatment  by  cath- 
eterism  is  a  novelty.  In  the  old  and  well-worn  cases  it  is  not  so 
liable  to  occur.  Unusual  gentleness  in  the  use  of  the  catheter  is 
called  for  in  these  cases  of  cystitis  with  enlarged  prostate. 

What  complications  come  on  later  in  the  course  of  prostatic  hyper- 
trophy ? 

Atony  of  the  bladder  from  its  inability  to  overcome  the  pros- 
tatic obstruction  and  entirely  empty  itself;  chronic  cystitis  as  a 
result  of  the  retention  and  decomposition  of  the  urine  ;  urinary 


94  THE   PEOSTATE   GLAND. 

calculi ;  and  finally  the  inflammation  may  be  driven  up  the  ureters 

to  the  pelvis  of  the  kidneys  and  result  in  pyelitis. 

What  internal  treatment  is  useful  in  these  cases  of  prostatic  hyper- 
trophy ? 

Anodynes  in  sufficient  quantity  only  to  allay  pain,  under  which 
circumstances  the  patient  should  be  sent  to  bed,  so  that  the  bladder 
may  have  the  greatest  amount  of  rest  possible,  and,  by  raising  the 
hips  with  a  pillow,  that  freer  drainage  of  venous  blood  from  the 
pelvis  may  occur ;  counter -irritation  or  poultices  ajDplied  to  the  hy- 
pogastrium,  and  the  rectum  emptied, — all  of  which  means  will  assist 
in  determining  the  smallest  amount  of  anodyne  which  it  is  necessary 
to  use  in  a  given  case.  The  only  other  internal  remedies  which 
seem  to  render  service  are  those  which  tend  to  sterilize  the  urine 
and  possess  diuretic  properties,  such  as  salol,  in  doses  of  from  5  to 
10  grains  three  or  four  times  daily,  possibly  combined  with  fluid 
extract  of  pechi,  10  or  15  minims  at  a  dose,  and  the  employment 
of  such  waters  as  tend  to  thin  and  increase  the  urine,  such  as 
Poland  or  the  New  Highland  Spring  water.  If  partial  suppression 
sets  in,  copious  draughts  of  these  waters  should  be  employed, 
together  with  diuretin  or  some  other  diuretic,  which  the  physician 
is  apt  to  elect  according  to  his  special  liking. 

What  are  the  surgical  means  which  may  be  employed  for  the 
radical  relief  of  the  conditions  accompanying  hypertrophied 
prostate  ? 

Disregarding  old  methods,  which  have  been  accompanied  by  only 
a  small  showing  of  success,  it  may  be  said  that  there  is  only  a 
choice  between  two  surgical  procedures — namely,  either  suprapubic 
cystotomy,  by  opening  the  bladder  above  the  pubis  and  reaching 
directly  the  hypertrophied  ofi'ending  portion,  or  perineal  section. 
The  former  of  these  two  operations  is  rapidly  gaining  reputation  at 
the  present  day,  and,  while  it  is  a  procedure  of  gravity,  yet  from 
the  fact  that  it  has  to  offer,  for  successful  cases,  a  far  better  con- 
dition of  affairs  after  the  operation  than  any  other  surgical  inter- 
ference, the  probability  is  that  it  will  forestall  eventually  these 
other  older  methods,  and  stand  alone  as  the  only  reliable  means  to 
be  held  out  to  a  patient  for  permanent  relief. 

What  is  the  most  common  complication  which  tends  to  lead  to 
a  fatal  issue  in  cases  of  prostatic  hypertrophy  ? 

Inflammation  of  the  ureters,  which  is  very  liable  to  accompany 
these  cases  and  which  may  lead  to  a  pyelitis,  is  a  very  serious 


PKOSTATITIS.  95 

condition,  which  is  aggravated  by  cold,  imprudence  of  living,  and 
under  these  conditions  a  mild  uraemia  develops,  accompanied  by 
symptoms  of  a  general  anorexia,  a. dry  skin,  a  reddened  and  dry 
condition  of  the  tongue,  headache,  slight  delirium,  albumin  in  the 
urine.  A  fatal  termination  under  these  circumstances  is  likely 
to  occur. 

What  is  the  treatment  of  this  complication  ? 

Confinement  to  bed  in  a  warm  room,  measures  to  excite  the 
action  of  the  skin  and  the  bowels,  the  free  and  copious  use  of 
diuretic  waters,  and  a  milk  diet ;  the  use  of  diuretin  in  doses  of 
10  grains  every  two  hours. 

What  other  affections  of  the  prostate  has  the  physician  to  deal 
with  which  are  not  brought  so  prominently  to  his  notice  as 
hypertrophy  ? 

Prostatitis;  simple  congestion  of  the  prostate,  parenchymatous, 
gonorrhoeal,  and  tubercular ;  abscess  of  the  prostate ;  syphilis  of 
the  prostate ;  cancer  of  the  prostate ;  prostatic  concretions  and 
prostatic  calculi ;  neuralgia  of  the  prostatic  urethra. 

PROSTATITIS. 
What  is  the  cause  of  congestion  of  the  prostate  ? 

It  occurs  physiologically  during  any  sexual  excitement,  and  is 
induced  by  any  of  the  means  which  tend  to  excite  a  sexual  appe- 
tite; but  when  this  condition  of  hyperaemia  is  unduly  prolonged 
without  obtaining  physiological  relief,  the  organ  may  remain  con- 
gested, giving  the  sensation  of  being  tense  and  hard,  with  a  fre- 
quent desire  to  urinate,  and  be  accompanied  by  a  small  gleety 
discharge.  This  same  condition  may  be  excited  by  sexual  excess, 
masturbation,  etc.,  which  may  lead  to  a  chronic  condition.  It  may 
complicate  gonorrhoea,  and  is  generally  a  concomitant  of  stricture. 

How  can  it  be  relieved? 

In  its  simple  form  it  generally  yields  to  rest  and  a  cold  or  hot 

sitz-bath. 

What  is  parenchymatous  prostatitis? 

Inflammation  of  the  substance  of  the  organ,  generally  traumatic, 
or  an  extension  of  inflammation  from  other  parts,  seldom  idiopathic. 
It  may  be  caused  by  gonorrhoea,  stricture,  excessive  venery,  concen- 
trated urine,  cold,  and  mechanical  means,  such  as  instruments  or 
foreign  bodies.     The  gonorrhoeal  inflammation  may  be  driven  to  the 


96  THE   PROSTATE   GLAND. 

prostate  very  rapidly  by  the  excesses  of  the  patient.  It  generally 
commences  as  a  congestion,  and  during  resolution  produces  a  dis- 
charge from  the  surface  ;  it  may  lead  to  abscess,  and  may  become 
a  chronic  inflammation. 

What  are  the  symptoms? 

The  organ  swells  rapidly,  and  the  condition  announces  itself  by 
a  feeling  of  tension,  and  the  enlargement  may  be  felt  as  a  hard  mass 
in  the  rectum,  throbbing,  sensitive,  and  hard.  Pressure  on  or  about 
it  produces  the  desire  to  urinate.  These  sensations  of  heat  and 
throbbing  are  felt  by  the  patient  himself,  and  may  be  accompanied 
by  pain  in  the  back  and  in  the  limbs.  If  it  be  a  concomitant  of  a 
previous  discharge  from  the  urethra  from  a  gonorrhcea  or  gleet,  the 
discharge  is  reduced  in  quantity  and  in  density,  to  return  when  the 
inflammation  subsides.  The  stream  during  urination  is  small  and 
the  act  labored.  The  swelling  may  be  such  as  to  cause  temporary 
retention.  The  congestion  of  the  neck  of  the  bladder  which  inva- 
riably accompanies  it  produces  the  constant  and  unsatisfied  desire 
to  pass  the  water,  so  that  even  when  the  bladder  is  perfectly  empty 
this  feeling  still  exists.  In  regard  to  pain,  it  is  felt  during  the  pas- 
sage of  the  urine,  but  is  most  acute  when  the  last  drops  are  being 
expelled,  as  the  bladder  contracts  down  upon  the  sensitive  organ, 
often  expelling  blood  derived  from  the  congested  vessels,  and  thus 
discharging  the  blood  with  the  last  remnant  of  the  urine.  It  is 
similar  to  that  felt  from  stone  in  the  bladder,  and  runs  from  the 
perineum  to  the  end  of  the  penis  on  its  under  surface.  The  febrile 
disturbances  accompanying  it  are  very  marked,  and  the  excitement 
of  the  patient  is  apt  to  be  great.  If  the  disease  attack  the  seminal 
vesicles,  spermatozoa  are  discovered  in  the  discharge.  A  false  mem- 
brane may  rarely  form. 

If  resolution  occurs,  when  does  it  take  place  ? 

Generally  not  later  than  the  twelfth  day,  and  recovery  is  not 
complete  until  about  three  weeks  ;  but  instead  of  going  to  resolu- 
tion the  inflammation  may  become  chronic  as  a  "  folliculitis  "  or  as 
an  interstitial  inflammation,  which  may  lead  to  an  indurated  condi- 
tion simulating  hypertrophy. 

What  is  the  treatment  of  prostatitis  ? 

Absolute  rest  is  necessary.  An  alkaline  diluent  and  an  anodyne 
sufficient  to  control  the  pain  and  the  excessive  desire  to  urinate  should 
be  given.     Moderate  draughts  of  certain  mineral  waters,  such  as  the 


PROSTATITIS.  97 

Highland  or  Poland  Spring,  are  useful  as  diluents,  although  if 
there  be  much  congestion  of  the  neck  of  the  bladder  the  bulk  of 
urine  should  not  be  largely  increased.  If  the  affection  comes  on 
during  gonorrhoea,  treatment  for  the  latter  should  be  discontinued, 
especially  the  injections,  and  if  the  inflammation  and  tension  be  suf- 
ficient, such  active  means  as  leeching  or  bleeding  may  be  resorted 
to.  If  retention  complicates  the  case  a  small  soft  instrument  should 
be  gently  introduced. 

If  either  of  thiese  former  conditions  lead  to  abscess  in  or  around  the 
prostate,  what  are  the  symptoms? 
All  the  symptoms  of  the  inflammation  become  aggravated,  throb- 
bing is  more  marked,  and  the  pains  less  dull  and  more  lancinating. 
The  condition  is  generally  ushered  in  by  a  chill,  and  the  pus  as  it 
burrows  toward  the  urethra  causes  a  still  greater  diminution  in  its 
calibre,  which  may  become  obliterated  and  result  in  retention.  The 
whole  substance  of  the  prostate  may  suppurate  or  it  may  contain 
multiple  suppurating  foci.  The  abscess  may  burrow  toward  the 
urethra,  bladder,  or  rectum  or  through  the  perineum,  and  if  left 
alone  discharge  at  these  different  situations. 

What  is  the  outcome  of  this  condition  ? 

If  the  abscess  opens  spontaneously  or  is  incised,  almost  immedi- 
ate relief  from  the  symptoms  is  experienced.  If  only  a  small  focus 
exists,  it  may  not  burrow  nor  point,  but  the  pus  becomes  absorbed 
and  leaves  behind  a  calcareous  concretion.  The  usual  course  after 
the  abscess  has  opened  is  that  of  cicatrization,  repair  being  by 
granulation  ;  but  this  process  may  be  interfered  with  by  communi- 
cation with  the  bladder  or  rectum,  and  thus  materially  interfere 
with  the  prognosis,  which  is  ordinarily  good  unless  this  latter  con- 
dition exists  or  the  collection  of  pus  be  very  extensive.  If  the 
abscess  exists  not  in  the  prostate,  but  in  the  tissues  around  it  as 
the  result  of  the  same  causes,  the  symptoms  are  the  same,  but  less 
intense.  It  is  then  termed  ^periprostatic  abscess.  In  this  condition 
a  finger  in  the  rectum  will  distinguish  oedema  on  either  side  instead 
of  a  clearly-defined  and  over-distended  throbbing  prostate.  It  may 
point  and  open  in  a  similar  manner  to  the  prostatic  abscess. 

What  is  the  treatment  of  these  conditions  ? 

Whenever  fluctuation  can  be  distinguished  through  the  rectum, 
a  trocar  should  be  introduced  at  once  and  a  puncture  made  to  pre- 
vent burrowing  and  allay  the  symptoms.     After  the  abscess  has 

7— G-U. 


^8  THE   PROSTATE   GLAND. 

burst  the  treatment  is  rational.  When  no  fluctuation  can  be  dis- 
tinguished and  retention  supervenes,  its  coming  must  be  watched 
for  and  catheterism  or  aspiration  practised  meanwhile. 

What  is  follicular  prostatitis  ? 

Follicular  prostatitis,  or  "  prostatorrhcea,"  is  inflammation  of  the 
mucous  membrane  and  follicles  and  ducts  and  the  sinus  of  the 
prostate,  the  substance  of  the  organ  not  being  involved.  It  starts 
as  a  subacute  affection,  generally  in  the  course  of  a  gonorrhoea  when 
it  has  reached  this  depth,  and  runs  a  chronic  course,  with  possible 
acute  exacerbations  brought  on  by  excess  or  neglect. 

What  are  its  symptoms  ? 

A  slight  muco-purulent  discharge  exaggerated  by  muscular  effort, 
especially  during  defecation,  when  it  may  appear  from  the  meatus 
in  pulpy  lumps  and  be  taken  by  the  patient  for  spermatorrhoea. 
Examination  by  the  microscope  will  show  the  absence  of  spermatic 
elements  and  the  presence  only  of  fatty  material,  epithelium,  and 
pus-cells. 

What  are  the  symptoms  accompanying  this  condition  ? 

If  follicular  prostatitis  be  accompanied  by  a  certain  amount  of 
parenchymatous  inflammation,  as  is  apt  to  be  the  case,  the  symp- 
toms of  both  affections  present  themselves  in  combination.  A 
certain  amount  of  weight  may  be  felt  in  the  perineum,  increased 
on  exercise ;  defecation  may  be  painful,  added  to  which  is  the  fre- 
quency of  urination  in  a  variable  degree.  The  urine  contains  pus, 
and  blood  sometimes  accompanies  the  end  of  the  stream.  The  pain 
felt  during  urination  is  at  the  neck  of  the  bladder  and  at  the  end 
of  the  penis  at  the  finish  of  urination.  There  is  apt  to  be  a  spas- 
modic condition  of  the  bladder  and  of  the  *' cut-off"  muscle,  the 
latter  acting  sometimes  so  as  to  interrupt  the  flow.  Other  symp- 
toms of  general  depression,  constitutional  and  emotional,  are  present. 
The  slight  gleety  discharge  is  very  persistent  against  treatment. 
In  all  these  cases  an  exploration  for  stone  should  be  made,  as  the 
symptoms  so  closely  resemble  this  latter  condition. 

What  is  the  treatment  of  follicular  prostatitis? 

Repeated  blistering  of  the  perineum  by  cantharidal  collodion  is 
said  to  be  very  efficacious,  confining  the  patient  to  the  bed  and 
making  the  application  alternately  on  either  side.  The  usual  course 
of  alkaline  diluents  should  be  observed,  and  this  course  is  to  be 
kept  up  until  relief  is   felt,  which  may  come  in  a  few  weeks,  but 


SYPHILIS    AND    CANCER.  99 

the  disease  may  be  very  persistent  and  last  a  long  time.  A  fre- 
quently valuable  adjuvant  to  the  treatment  is  the  local  applica- 
tion of  a  mild  solution  of  nitrate  of  silver,  from  5  to  10  grains  to 
the  ounce,  in  the  membranous  urethra  at  intervals  of  four  or  five 
days. 

What  is  tubercular  prostatitis? 

A  form  of  chronic  prostatitis  which  appears  in  tuberculous, 
scrofulous,  and  broken-down  subjects,  characterized  by  cheesy  de- 
generation in  the  ducts  and  follicles  of  the  prostatic  sinus.  If  this 
material  be  small  and  situated  only  around  the  sinus,  it  is  hard  to 
establish  a  diagnosis  of  the  disease,  but  if  abundant  the  organ 
can  be  felt  through  the  rectum  in  a  lumpy  condition,  or  the  two 
vasa  deferentia  can  be  distinguished  as  hard  cords  running  from 
enlarged  inodular  seminal  vesicles.  The  epididymis  is  apt  to  be 
the  seat  of  tuberculous  foci,  as  may  be  the  lungs  or  other  organs. 

What  are  the  symptoms  of  tubercular  prostatitis? 

The  same  as  severe  chronic  prostatitis,  with  a  slow  and  persistent 
course,  the  symptoms  varying  in  their  intensity  from  time  to  time. 
Ulcerations  form  in  the  prostate,  as  do  abscesses  from  different  foci, 
leaving  cavities  or  fistulas  with  a  great  lack  of  tendency  to  heal. 
Hemorrhage  from  the  urethra  appears  at  different  times.  The 
prognosis  of  the  disease  is  very  bad.  Death  occurs  from  general 
undermining  of  the  system  from  tuberculosis.  If  recovery  from 
this  affection  occurs,  it  does  so  only  under  fortunate  hygienic  sur- 
roundings. 

What  is  the  treatment  of  tubercular  prostatitis  ? 

The  treatment  aims  at  the  general  more  than  the  local  condition, 
but  the  same  measures  adopted  for  the  other  forms  of  chronic  pros- 
tatitis may  be  resorted  to  with  some  effect. 

SYPHILIS  AND  CANCER  OF  THE  PROSTATE. 
Does  syphilis  often  affect  the  prostate  ? 

No,  but  it  is  possible  for  it  to  appear  here  in  its  own  peculiar 
way.     There  is  no  special  syphilitic  condition  of  the  prostate. 

How  does  cancer  affect  the  prostate  ? 

Rarely  as  a  primary  growth,  usually  secondary  to  disease  of  the 
kidney  or  testicle.  It  may  appear  in  any  of  its  different  forms, 
generally  in  advanced  life. 


100  THE   PROSTATE   GLAND. 

What  are  the  symptoms  of  cancer  of  the  prostate  ? 

They  are,  first,  those  of  obstruction,  causing  increased  desire  to 
urinate,  which  is  accompanied  by  pain.  The  general  symptoms  re- 
semble more  or  less  those  of  hypertrophy  and  inflammatory  enlarge- 
ment, but  they  do  not  occur  so  rapidly  as  the  latter  nor  so  grad- 
ually as  the  former.  When  the  condition  is  superadded  to  a  pre- 
existing hypertrophied  condition,  it  is  very  difficult  to  establish  a 
diagnosis.  Scirrhous  cancer  would  be  characterized  by  a  feeling  of 
unexceptional  hardness  in  examination  per  rectum,  while  medullary 
cancer  would  reveal  an  irregularity  in  the  enlargement  and  softened 
spots,  of  greater  or  less  extent,  in  various  places.  The  pelvic  and 
inguinal  glands  in  cancer  become  enlarged  and  take  on  the  cha- 
racter of  this  disease.  Of  course  the  existence  of  the  disease  in 
other  situations  will  lend  a  suspicion  to  its  probable  propagation 
here.  The  records  show  that  cancer  is  not  propagated  from  the 
bladder  to  the  prostate,  but  the  reverse  order  has  been  seen  and 
reported,  as  also  secondary  cancer  in  the  prostate  following  the 
primary  condition  in  the  rectum.  Finally,  after  a  sufficient  length 
of  time,  the  cancerous  cachexia  marks  the  presence  of  this  dire 
disease.  The  hemorrhage  which  occurs  with  cancer  of  the  prostate 
is  free  and  arterial  in  character,  and  generally  comes  on  during 
urination,  although  not  necessarily.  The  urine  is  purulent,  bloody, 
full  of  debris,  and  very  offensive  in  character.  The  disease  tends 
toward  a  fatal  issue  in  from  one  to  five  years. 

What  is  the  treatment? 

The  treatment  consists  in  an  employment  of  such  rational  and 
symptomatic  measures  as  are  required  in  inflammatory  conditions 
of  the  prostate,  aiming  at  relieving  the  bladder  from  over-disten- 
sion and  the  prostate  from  any  unnecessary  work  by  the  use  of  the 
catheter,  purifying  the  urine  as  much  as  possible  by  washing  the 
bladder,  and  the  use  of  alkalines  and  anodynes  in  sufficient  quan- 
tity to  render  the  patient  comfortable. 

PROSTATIC  CONCRETIONS  AND  CALCULI. 
What  are  prostatic  concretions? 

They  resemble  in  character  concretions  found  in  the  salivary 
glands  or  biliary  ducts,  and,  while  they  cannot  properly  be  called 
calculi,  they  may  form  a  nidus  around  which  the  calculus  may 
form.     They  occupy  the  ducts  and  follicles  of  the  prostate,  and  in 


PROSTATIC   COXCRETIONS. 


101 


their  growth  impinge  upon  the  neighboring  substance  and  some- 
times attain  the  size  of  a  pea.  They  are  not  of  urinary  forma- 
tion, but  are  derived  from  the  retained  secretions  of  obstructed 
ducts  or  small  abscess  foci  which  have  undergone  resolution,  when 
they  form  the  nuclei  for  prostatic  stones.  They  become  sources  of 
deposit  for  earthy  phosphates,  by  which  they  may  go  on  indefinitely 
increasing  in  size  and  assuming  various  shapes.  They  then  consti- 
tute prostatic  calculi,  which  if  they  continue  to  increase  in  size  may 
produce  many  of  the  symptoms  already  mentioned  as  a  result  of 
prostatic  obstruction,  and  sometimes  may  be  felt  by  the  passage  of 
an  instrument  into  the  bladder.  The  natural  sequence  of  these  con- 
cretions when  they  exist  in  a  sufficient  degree  to  cause  irritation  is 
the  formation  of  abscesses,  as  the  result  of  which  they  may  dis- 
charge externally.  They  may  ulcerate  through  the  rectum  or  into 
the  urethra. 

What  is  the  treatment  for  the  concretions  and  calculi  ? 

If  they  be  of  sufficient  size  to  cause  a  great  deal  of  irritation, 
and  perhaps  obstruction  to  the  urinary  flow,  they  may  possibly  be  re- 
moved by  an  urethral  forceps  (see  Figs.  11,  A,  and  11,  B),  but  if  their 


Fig.  11,  A. 


Urethral  Forceps. 

Fig.  11,  B. 


Urethral  Forceps. 


existence  be  established  beyond  doubt,  the  best  method  is  to  cut 
through  the  perineum  and  remove  the  foreign  bodies  in  this  man- 
If  they  can  be  more  prominently  felt  by  examination  per 


ner 


102  THE   PROSTATE   GLAND. 

rectum,  it  may  be  advisable  to  make  an  incision  througb  this  region 
and  remove  them  all  here.  In  all  cases  where  they  exist  it  is  well 
to  search  the  bladder  for  stone,  as  the  two  conditions  are  apt  to 
coexist. 

PROSTATIC  NEURALGIA. 

What  is  neuralgia  of  the  prostatic  urethra  ?  and  where  is  it  situ- 
ated? 

Neuralgia  of  the  prostate  is  a  functional  disorder,  largely  of  a 
neurotic  character,  and  situated  in  the  prostatic  sinus,  around  the 
seminal  ducts,  and  affecting  also  the  neck  of  the  bladder. 

What  are  the  causes  of  this  disorder  ? 

Its  causes  are  those  which  are  derived  from  inordinate,  unnatural, 
and  unsatiated  sexual  appetite,  the  result  of  which  causes  tends  to 
congestion  and  irritation  of  this  affected  area.  Besides  the  causes 
named  of  this  neurotic  condition,  we  have  the  rheumatic  and  gouty 
diatheses  and  any  of  the  different  conditions  which  involve  a  sym- 
pathetic or  structural  change  of  the  tissues  around  this  region — 
namely,  inflammation,  stricture,  hypertrophy  of  the  prostate,  hem- 
orrhoids, worms,  etc.  This  affection  rarely  occurs  as  an  idiopathic 
condition.  It  is  always  accompanied  by  some  adjacent  inflammation 
or  some  perversion  of  the  sexual  appetite.  It  generally  appears  in 
those  men,  old  and  young,  who  have  a  strong  desire  and  yet  cannot 
have  their  sexual  appetite  satisfied.  In  other  words,  an  inquiry 
into  the  history  of  these  cases  will  generally  reveal  that  it  is  the 
mind  of  the  patient  which  is  the  main  exciting  cause  of  this  unfor- 
tunate condition. 

What  are  the  symptoms  accompanying  this  neuralgia  of  the  pros- 
tatic urethra  or  vesical  neck? 

The  subjective  symptoms  are  those  of  irritability,  frequent  desire 
to  urinate,  coming  on,  in  those  with  erotic  fancies,  suddenly  or  per- 
haps following  an  attack  of  gonorrhoea.  The  passage  of  urine  may 
or  may  not  be  accompanied  by  pain.  In  severe  cases  it  is  frequently 
followed  by  tenesmus  or  cramp,  experienced  in  the  deep  portion  of 
the  urethra,  or  there  may  be  a  spasm  of  the  "  cut-off"  muscle  and 
inability  to  urinate.  This  frequent  desire  to  urinate  rarely  affects 
the  patient  at  night.  Unless  rendered  wakeful  by  some  other  wor- 
riment,  he  generally  spends  a  night  of  sound  sleep,  and  it  is  only 
during  the  day  or  during  icakeful  hours  of  the  night,  when  his  mind 
is  free  to  act,  that  this  symptom  especially  reveals  itself.  When  prop- 


PROSTATIC   NEURALGIA.  103 

erly  preoccupied  by  healthful  amusement,  or  even  when  under  the 
partial  influence  of  liquor,  the  mind  of  the  patient  is  taken  from 
this  portion  of  his  body  and  the  symptom  of  frequent  urination  is 
not  present.  The  spirits  are  usually  depressed  and  the  patient  more 
or  less  hypochondriacal.  If  the  urine  contains  any  deposit,  it  con- 
sists of  amorphous  phosphates,  and  crystals  of  oxalate  of  lime  are 
not  uncommonly  present.  The  erections  may  be  unnaturally  fre- 
quent or  abnormally  absent,  and  there  may  be  more  or  less  heat 
and  tenderness  around  the  region  of  the  external  genitals.  Other 
neurotic  conditions  may  coexist  with  it,  such  as  spasmodic  stricture, 
irritable  "  cut-off"  muscle,  and  nocturnal  incontinence.  Explora- 
tion of  the  urethra  with  a  blunt  steel  instrument  will  generally  find 
the  whole  canal  in  an  hypersensitive  condition  and  spasm  at  the  "  cut- 
off" muscle:  as  the  sound  enters  the  prostatic  region  a  peculiar 
feeling  of  nausea  and  faintness  may  be  experienced,  accompanied 
by  an  exaggerated  desire  to  urinate  or  an  entire  absence  of  this  sen- 
sation. This  exploration  is  apt  to  be  followed  by  the  passage  from 
the  urethra  of  a  small  amount  of  blood.  Subsequently,  however, 
this  procedure  generally  results  in  a  certain  amount  of  relief  to  the 
patient.  There  is  no  end  to  the  varied  number  of  neurotic  condi- 
tions which  may  coexist  with  this  trouble,  and  from  this  coexist- 
ence it  may  be  said  that  no  organ  or  function  of  the  body  is 
exempt. 

The  diagnosis  of  the  affection  may  generally  be  based  upon  the 
extreme  sensibility  of  the  prostatic  urethra  and  vesical  neck,  and 
the  absence  of  those  physical  conditions  which  indicate  the  exist- 
ence of  cystitis  or  the  different  forms  of  prostatitis.  Where  these 
affections  coexist  it  is  not  difficult  to  distinguish  the  neuralgic 
element. 

What  is  the  treatment  of  this  malady  ? 

There  is  hardly  any  condition  or  affection  of  the  genito-urinary 
system  which  requires  such  careful  deliberation  and  offers  such  a 
scope  for  effective  study  as  does  this  malady.  The  general  hygienic 
treatment  is  important,  such  as  liberal  outdoor  exercise  and  all 
those  practices  which  tend  to  invigorate  the  general  bodily  health, 
such  as  cold  bathing,  early  rising,  and  the  like,  and  if  possible 
inducing  the  natural  physiological  exercise  of  the  genital  organs — 
namely,  marriage.  Alkalines  may  be  indicated,  or  possibly  a  min- 
eral acid  if  there  be  a  tendency  to  excessive  phosphates,  and  a 
general  avoidance  of  excesses,  with  an  endeavor  to  preoccupy  the 


104  DISEASES   OF   THE   BLADDEK. 

mind — which  is  an  important  element  in  the  causation  of  this  affec- 
tion— by  interesting  and  regular  work.  In  regard  to  local  measures 
there  is  nothing  so  effective  as  the  occasional  introduction  of  a 
blunt,  smooth  steel  instrument  at  intervals  depending  upon  the 
effect  of  each  application.  If  cystitis  or  prostatitis  coexists,  this 
procedure  will  tend  more  to  irritate  than  to  relieve.  Where  there 
is  a  morbid  sensibility  in  these  parts,  the  gentle  and  equable  pres- 
sure of  the  instrument  seems  to  favorably  affect  the  irritated  mus- 
cles and  the  overloaded  vessels.  Finally,  instillations  of  nitrate-of- 
silver  solutions  find  an  efficacy  in  some  cases. 


DISEASES  OF  THE  BLADDER. 

What  is  the  position  and  general  anatomy  of  the  male  bladder  ? 

It  lies  between  the  rectum  and  the  pubic  bone  when  flaccid,  and 
when  distended  rises  up  into  the  hypogastrium.  It  is  covered 
above  and  on  the  sides  by  the  peritoneum.  This  latter  is  reflected 
from  the  symphysis  pubis  on  to  the  upper  surface  and  base  of 
the  bladder,  and  from  here  to  the  rectum.  When  the  bladder 
is  in  its  flaccid  state  there  lies  a  fold  of  the  peritoneum  between 
it  and  the  rectum  ;  but  during  distension  they  are  in  relation  with 
each  other.  As  also  in  front,  a  full  bladder  renders  a  surface  of 
several  inches  above  the  pubis  uncovered  by  peritoneum.  This 
is  an  important  point  to  be  familiar  with  when  the  question  of 
puncturing  the  bladder  for  aspiration  arises.  The  muscular  coat 
of  the  bladder  is  composed  of  two  separate  layers  of  fibres — 
an  external,  which  runs  longitudinally,  and  an  internal,  with  a 
general  circular  direction  at  the  neck  of  the  bladder  ;  these  lat- 
ter, increasing  in  density,  have  acquired  the  name  of  the  sphincter 
vesicae.  The  mucous  membrane  of  the  bladder  is  covered  by  pave- 
ment epithelium  and  is  of  a  pale  salmon  hue.  The  neck  of  the 
bladder  is  that  portion  encircled  by  the  so-called  sphincter,  and  in- 
cludes the  base  of  the  prostate.  The  trigone  is  a  triangular  space 
with  its  base  upward  toward  the  openings  of  the  ureters,  where  there 
is  a  muscular  ridge  joining  them,  by  which  it  is  limited,  and  its 
apex  downward  toward  the  neck  of  the  bladder.  The  "  bas-fond  " 
lies  posterior  to  the  trigone  in  middle  life,  when  it  only  exists,  and 
in  old  age  during  distension  it  lies  on  a  lower  plane  than  the  trigone. 
The  urachus  is  the  remains  of  an  embryonic  prolongation  to  the 
umbilicus,  which  normally  after  birth  is  impervious. 


ANOMALIES   AND   DEFORMITIES.  105 

What  anomalies  and  deformities  of  the  bladder  occur  ? 

Sacculi  of  various  dimensions  ;  sometimes  as  large  or  larger  than 
the  bladder  itself,  being  herniae  of  the  mucous  coat  through  the 
other  tissues  of  the  bladder,  and  are  therefore  without  a  muscular 
coat.  Partial  partitions  entering  into  the  bladder  have  been 
reported.  The  bladder  is  sometimes  unnaturally  small  and  rarely 
entirely  wanting,  under  which  circumstances  the  ureters  open  into 
the  urethra  or  into  the  rectum.  More  than  one  bladder  has  existed 
in  one  individual.  Exstrophy  of  the  bladder  is  a  deformity,  the 
result  of  an  arrest  of  development  in  the  median  line  of  the  abdo- 
men, and  exists  in  different  degrees.  There  may  be  an  absence  of 
the  lower  front  wall  of  the  abdomen  and  of  the  bladder,  the  pubic 
bones  being  separated  and  the  posterior  wall  of  the  bladder  being 
pushed  forward  between  them.  Inguinal  hernia,  complete  or  incom- 
plete, may  be  present  on  both  sides.  This  condition  may  be  more 
or  less  modified,  and  when  complete  is  generally  accompanied  by 
epispadias. 

The  treatment  involves  a  plastic  operation,  the  nature  of  which 
must  vary  with  each  case. 

Does  hernia  of  the  bladder  occur  ? 

A  dislocation  of  this  organ  may  exist  which  may  be  rarely 
congenital,  but  comes  on  generally  late  in  life  as  the  result  of  over- 
distension or  violence.  It  may  or  may  not  be  accompanied  by  a 
portion  of  the  intestines,  and  it  appears  in  the  various  localities 
through  which  the  gut  is  liable  to  protrude. 

The  diagnosis  is  made  by  the  passage  of  a  catheter  into  the  blad- 
der and  reduction  of  its  diameter  by  diminution  of  the  contents. 

The  treatment  is  to  retain  it  in  place  by  means  of  a  truss,  if  it 
be  reducible ;  otherwise  the  tumor  must  be  furnished  with  sup- 
port. Strangulation  would  require  an  operation  for  its  relief. 
An  operation  may  also  be  performed  with  a  view  of  affording 
radical  relief. 

Does  hypertrophy  of  the  bladder  occur,  and  if  so,  when  ? 

It  occurs  as  an  accompaniment  of  the  hypertrophied  prostate  or 
any  other  condition  which  produces  obstruction  or  impediment  to 
the  flow  of  urine. 

Is  atrophy  of  the  bladder  sometimes  met  with  ? 

In  debilitated  and  broken-down  subjects  a  weakened,  soft,  and 


106  DISEASES   OF   THE   BLADDER. 

thin  bladder  may  exist ;  so  mucli  so  tliat  it  predisposes  to  rupture 
when  roughly  dealt  with. 

What  other  causes  combine  to  produce  rupture  of  the  bladder  ? 
Ulceration,  over-distension,  and  external  violence. 

What  are  the  symptoms  of  this  condition  ? 

Sudden  pain  following  a  fall  or  an  injury  while  the  bladder  has 
been  distended  ;  rapid  collapse,  during  which  the  patient  may  die 
from  shock  ;  or  may  partially  recover  from  this  ;  soon  to  be  followed 
by  acute  peritonitis.  Desire  to  urinate  is  a  frequent  and  constant 
symptom  at  the  time  and  following  the  accident.  It  is  apt  to  be 
impossible  to  satisfy  this  desire.  If  the  catheter  be  passed  the 
urine  is  very  apt  to  be  tinged  with  blood,  but  may  come  away 
clear. 

What  is  the  treatment  ? 

If  the  diagnosis  be  established,  suprapubic  cystotomy  is  the 
surgical  means  to  adopt,  and  a  laparotomy  should  also  be  done 
if  a  rent  in  the  peritoneum  be  suspected  or  if  the  bladder  is  seri- 
ously torn.  If  the  diagnosis  is  uncertain,  but  reasonably  sure,  an 
exploratory  operation  is  indicated. 

What  is  incontinence  of  urine  ? 

Incontinence  is  where  the  urine,  in  part  or  in  whole,  passes  away 
involuntarily  as  a  result  of  paralysis  of  the  "  cut-off"  and  sphincter 
muscles.  It  is  therefore  a  symptom  of  other  conditions,  like  reten- 
tion. In  an  adult  the  dribbling  of  urine  which  sometimes  occurs 
with  enlarged  prostate  and  other  conditions  means  retention,  as  a 
rule,  the  result  of  over-distension,  and  occurs  as  an  "  overflow." 
Where  the  incontinence  is  not  the  result  of  an  overflow,  but  is  a 
true  incontinence,  it  is  caused  by  paralysis  of  the  cut-off  and 
sphincter  muscles :  inability  of  the  bladder  to  distend  on  account 
of  concentrated  hypertrophy ;  or  by  a  defective  development  in  a 
portion  of  the  prostate,  tending  to  allow  a  small  quantity  of  the 
urine  to  dribble  away  without  producing  distension  of  the  bladder. 
Occurring  in  children,  "nocturnal  incontinence"  is  an  involuntary 
flow  of  urine,  often  from  force  of  habit  and  improper  training. 
It  generally  passes  away  without  treatment,  but  sometimes  con- 
tinues until  the  child  is  old  enough  to  appreciate  its  infirmity 
without  being  able  to  overcome  it.  Such  children  are  not  neces- 
sarily  nervous    or    choreic.     Belladonna  pushed    to  physiological 


CYSTITIS.  107 

elFects  is  sometimes  useful  in  the  treatment.  Blistering  of  the 
perineum  has  been  suggested,  as  well  as  different  means  of  sealing 
the  meatus.  In  cases  where  a  long  foreskin  has  existed,  its  removal 
has  effected  a  cure.  But  even  at  this  advanced  age  attendance  to 
the  general  hygiene,  assisted  by  the  efforts  of  the  patient,  will 
suffice  to  effect  a  cure  in  time. 

CYSTITIS. 

What  diseases  of  the  bladder  have  we  to  consider  ? 

The  different  forms  of  cystitis,  acute  and  chronic,  interstitial 
cystitis  and  pericystitis. 

What  is  pericystitis  ? 

Inflammation  of  the  connective  tissue  surrounding  the  bladder. 
It  may  result  from  an  extension  of  inflammation,  but  is  generally 
caused  by  extravasation  of  urine  or  excessive  violence.  It  gener- 
ally tends  toward  a  point  of  suppuration. 

What  is  interstitial  cystitis  ? 

Inflammation  of  the  walls  of  the  bladder,  generally  an  extension 
of  a  severe  inflammation  of  the  mucous  membrane.  In  this  con- 
dition the  bladder  slowly  contracts,  and  its  walls  thicken  very  de- 
cidedly. Abscesses  may  form,  and  the  cavity  become  so  small  as 
to  hold  only  a  trivial  amount  of  urine,  thus  producing  incontinence. 
It  is  not  curable. 

What  are  the  causes  of  acute  cystitis  ? 

Traumatic  causes  ;  rough  treatment  or  neglect  during  a  chronic 
inflammation  ;  extension  of  inflammation,  gonorrhoea,  or  prostatitis. 
It  also  occurs  in  the  course  of  a  neuralgia  of  the  neck  and  the 
prostatic  sinus. 

What  are  the  symptoms? 

Frequent  desire  to  urinate  night  and  day,  the  response  to  which 
does  not  bring  relief;  pain  in  the  perineum  and  above  the  pubis, 
perhaps  running  down  to  the  end  of  the  penis  ;  pain  in  the  back  and 
down  the  thighs.  The  pain  is  possibly  increased  during  urination 
and  at  the  end  of  the  act.  The  urine  contains  more  or  less  pus, 
and  if  the  inflammation  be  severe  destructive  sloughy  shreds  will 
be  found  and  decomposition  will  be  present  in  variable  degrees. 
The  urine  may  be  first  acid,  but  soon  becomes  alkaline.  Under 
the  microscope  the  triple  and  amorphous  phosphates  are  found  in 


108  DISEASES   OF   THE   BLADDER. 

abundance,  blood  and  pus  free,  and,  in  clumps,  epithelial  debris, 
bacteria,  etc.  Febrile  symptoms  may  be  more  or  less  severe,  vary- 
ing in  different  cases.  When  it  occurs  during  the  course  of  a 
gonorrhoea,  it  generally  does  not  appear  until  after  the  third  week, 
when  inflammation  has  travelled  backward,  and  is  generally  con- 
fined to  the  neck  of  the  bladder.  It  may  come  simply  from  an  ex- 
tension of  the  inflammation  or  be  produced  by  excessive  exercise  or 
over-indulgence  in  drink.  The  symptoms  during  this  form  of  cys- 
titis may  be  very  mild  or  may  indicate  a  very  high  degree  of  irri- 
tability and  disturbance.  The  urethral  discharge  becomes  lessened 
and  may  disappear,  to  return  again  when  the  bladder  symptoms 
subside.     It  varies  in  duration  from  a  few  days  to  as  many  weeks. 

How  can  acute  prostatitis  be  distinguished  from  this  malady  ? 

By  examination  per  rectum,  which  reveals  the  tense,  swollen,  and 
throbbing  prostate. 

What  drug  taken  internally  in  excess  may  produce  cystitis  ? 

Cantharides.  This  condition  is  a  strangury,  being  a  congestion 
of  the  vessels  about  the  neck.  The  symptoms  are  those  of  tenes- 
mus, and  constant  erections  from  erotic  feelings  may  also  be  present. 

What  is  the  treatment  of  acute  cystitis  ? 

It  resembles  the  treatment  of  prostatitis — ^rest,  alkalines,  and  an 
anodyne  in  sufficient  quantity  to  allay  pain.  The  local  application 
of  heat  may  aid,  and  in  the  case  of  gonorrhosal  cystitis  a  deep  in- 
jection into  the  membranous  urethra  of  a  few  drops  of  solution  of 
nitrate  of  silver,  running  up  in  strength  from  1  to  48  grains  to  the 
ounce,  at  increasing  intervals.  This  often  produces  a  strangely 
beneficial  effect.  Of  course  when  any  cause  can  be  discovered,  such 
as  the  use  of  irritating  drugs,  as  cantharides,  turpentine,  or  cubebs, 
they  should  be  immediately  dispensed  with,  or  if  any  foreign  body 
exists  its  removal  should  be  effected. 

What  is  the  most  frequent  affection  of  the  bladder  ? 

Chronic  inflammation  or  catarrh. 

What  are  the  causes  of  this  condition  ? 

The  causes  are  mostly  of  a  mechanical  character,  such  as  obstruc- 
tion in  the  prostatic  or  other  portions  of  the  urethra,  stone  in  the 
bladder,  or  tumors,  or  any  of  the  conditions  which  would  modify  its 
normal  position  or  interfere  with  its  natural  function.  This  chronic 
eatarrh  may  also  be  reflex  from  disease  of  the  kidney. 


ATONY   AND   PARALYSIS.  109 

What  are  the  symptoms  of  chronic  cystitis  ? 

An  increased  desire  to  urinate  of  a  mucli  less  degree  than  in  acute 
cystitis.  The  urine  is  cloudy.  Pain  accompanies  the  urinary  act, 
varying  in  degree  and  character  in  different  cases.  These  cases  of 
chronic  cystitis  show  different  grades  of  symptoms,  resembling  more 
or  less  those  of  the  acute  trouble,  being  liable  under  certain  causes 
to  be  lighted  up  into  an  acute  stage,  so  that  the  symptoms  vary  in 
degree  anywhere  from  a  mild  chronic  case  to  all  the  signs  of  an 
acute  inflammation.  Pus  exists  in  the  urine,  free  and  in  shreds, 
more  or  less  mingled  with  triple  phosphates  and  blood. 

What  is  the  treatment  of  chronic  cystitis  ? 

Investigation  as  to  the  cause  upon  which  it  depends  and  removal 
of  the  same,  if  possible,  which  procedure  will  result  in  a  cure  of 
the  disease.  Where  there  exists  a  cause  which  cannot  be  removed, 
the  treatment  is  simply  symptomatic.  For  the  acute  outbreaks  on 
top  of  the  chronic  trouble  the  same  course  should  be  pursued  as  in 
the  ordinary  acute  form  of  the  disease.  The  urine  should  be  ren- 
dered alkaline,  and  such  other  treatment  as  laid  down  for  ordinarj^ 
acute  cystitis  be  employed. 

What  operation  is  sometimes  employed  for  the  purpose  of  benefiting 
a  bladder  suffering  from  chronic  cystitis  ? 
Perineal  cystotomy,  which  is  accomplished  by  a  median  incision 
in  the  perineum  and  by  the  tying  in  of  a  fair-sized  perineal  rubber 
tube,  which  is  left  in  place  to  effect  continuous  drainage  of  the 
inflamed  organ.  Washing  out  of  the  bladder  after  this  operation 
is  a  necessary  point  in  the  treatment  of  these  cases,  and  the  solu- 
tions to  be  used  for  this  treatment  are  the  same  as  in  the  acute 
form,  adding,  perhaps,  the  use  of  nitrate  of  silver  in  solution  from 
5  grain  to  3  grains  to  a  pint  of  water. 

ATONY  AND  PARALYSIS. 

What  is  atony  of  the  bladder  ? 

It  is  a  muscular  debility  or  lack  of  tone,  distinguished  from 
paralysis,  which  is  referable  to  the  nerve-centres,  while  atony  is 
entirely  a  local  malady.  A  physiological  atony  comes  on  with  age 
in  the  muscular  tissue  of  this  organ  as  well  as  in  the  other  portions 
of  the  body.  It  is  the  gradual  fatigue,  the  wavering  strength, 
which  as  age  advances  shows  the  loss  of  its  former  snap.  This 
pathological   condition   of  atony,  however,  comes  on  from   causes 


110  DISEASES   OF   THE    BLADDER. 

which  put  upon  the  bladder  too  much  strain,  and  has  no  necessary 
relation  to  the  age  of  the  individual.  A  mild  form  of  atony  may 
be  caused  by  an  irregularity  in  responding  to  the  calls  of  nature, 
necessitated  perhaps  by  occupation  or  by  the  lack  of  conveniences, 
which  circumstances  gradually  lead  to  an  impairment  of  the  expul- 
sive power  of  the  bladder — a  condition  which  is  the  result  of  con- 
tinually over-stretched  detrusor  urinae  muscles. 

What  is  the  cause  of  the  atony  which  accompanies  the  hyper- 
trophied  prostate? 

It  is  caused  by  the  continual  congestion  of  the  hypertrophied 
bladder  as  a  result  of  the  obstacle  to  venous  return  made  by  enlarge- 
ment of  the  prostate,  added  to  which  is  the  distension  to  which  the 
bladder  is  subjected  from  its  inability  to  entirely  empty  itself. 

What  are  the  symptoms  of  this  condition  ? 

In  its  complete  form,  where  there  is  a  total  loss  of  power,  the 
disabled  organ  allows  itself  to  be  filled  to  overflow,  and  we  have 
a  characteristic  dribbling  from  the  penis,  which  is  notably  seen  in 
cases  of  tight  stricture  and  prostatic  hypertrophy.  The  amount 
that  the  bladder  will  hold  in  these  cases  of  "  stagnation"  varies  in 
different  cases.  The  maximum  amount  having  been  reached,  any 
excess  causes  the  patient  to  have  the  ordinary  inclination  to  urinate. 
Percussion  over  the  pubis  will  reveal  an  overloaded  and  distended 
bladder.  The  most  conclusive  test,  however,  is  the  use  of  the 
catheter,  which  when  introduced  into  the  bladder  allows  the  out- 
ward flow  of  the  urine,  and  the  latter  in  coming  has  not  the  normal 
strength  and  force  of  stream  given  it  by  the  contraction  of  the 
bladder,  but  drops  from  the  end  of  the  instrument  with  the  force 
of  gravity  alone. 

What  is  the  treatment  of  atony  ? 

The  first  object  is  relief  to  the  overstretched  muscle  by  the  use 
of  the  catheter  to  withdraw  the  urine  at  ordinary  intervals,  after 
which  cold  injections  may  be  employed  for  the  purpose  of  giving 
tone  to  the  organ,  and,  if  the  condition  be  of  a  neurotic  nature,  by 
enjoining  the  patient  to  pass  his  urine  at  regular  intervals  whether 
he  feels  the  desire  for  it  or  not.  The  same  benefit  may  be  obtained 
by  applying  cold  externally  to  the  hypogastrium  or  perineum.  Very 
often  cold  injections  are  of  doubtful  utility,  as  the  introduction  of 
too  much  fluid  would  distend  the  organ  unnecessarily,  and  if  cystitis 
exists  with  this  affection,  the  cold  is  not  apt  to  benefit  it.     If  the 


MORBID    GROWTHS.  Ill 

condition  is  the  result  of  an  obstruction,  it  is  often  accompanied  by 
hypertrophy  of  the  muscular  walls  of  the  bladder,  and  therefore  so 
long  as  the  obstruction  exists  there  is  probably  little  benefit  to  be 
obtained  by  the  use  of  these  measures  ;  but  when  the  affection 
occurs  in  youth  and  middle  age,  depending  upon  a  neurotic  element, 
with  a  paralysis  of  the  detrusor  muscles,  it  is  amenable  to  treat- 
ment. In  such  cases  the  employment  of  electricity  may  be  added 
as- a  useful  adjuvant  for  its  relief.  One  electrode  is  carried  into  the 
bladder  and  another  into  the  rectum  or  over  the  hypogastrium. 

What  are  the  causes  of  paralysis  of  the  "bladder  ? 

It  generally  exists  with  diseases  of  the  central  nervous  system. 
It  may  occur  in  febrile  affections  complicated  by  cerebral  or  spinal 
affections,  when,  however,  it  is  apt  to  be  only  temporary. 

What  are  the  symptoms  of  paralysis  of  the  bladder  ? 

If  the  disease  exists  as  a  concomitant  of  some  nervous  affection 
and  comes  on  gradually,  affecting  only  the  detrusor  muscles  of  the 
bladder,  there  is  a  gradually  diminishing  force  to  the  flow  of  the 
urine  and  a  lack  of  power  to  entirely  evacuate  the  organ.  If  in- 
continence accompanies  this  form  of  the  disease,  it  is  not  true  in- 
continence, but  is  due  to  the  overflow  which  comes  from  an  over- 
distended  bladder,  and  therefore  appears  late  in  the  disease,  when 
the  evacuating  power  is  entirely  gone.  In  these  cases  the  urine 
smells  foul,  is  thick,  and  is  full  of  mucus  and  pus.  If  paralysis 
affects  the  sphincter  of  the  bladder — which  is  rare — true  inconti- 
nence will  occur. 

What  is  the  treatment  of  this  condition  ? 

The  most  satisfactory  treatment  is  the  use  of  the  catheter  at 
regular  intervals,  and  the  bladder  washed  if  cystitis  exists,  as  it  is 
very  apt  to.  The  same  care  is  to  be  used  in  the  management  of 
these  cases  in  the  withdrawal  of  the  entire  quantity  of  urine,  as  in 
cases  of  obstructive  retention  of  the  urine.  It  is  better  to  be 
wary  about  evacuating  with  a  catheter  the  bladder  which  has  long 
been  unable  to  evacuate  itself. 

MORBID  GROWTHS. 

What  morbid  deposits  and  growths  involve  and  grow  from  the 
bladder-walls  ? 

Tubercle,  benign  and  malignant  tumors. 


112  DISEASES   OF   THE   BLADDER. 

What  is  the  etiology  of  tubercle  as  it  affects  the  bladder- walls  ? 
It  occurs  in  connection  with  tuberculosis  of  other  parts,  fre- 
quently pulmonary  ;  sometimes  tuberculous  ulcerations  in  the  in- 
testinal track  ;  notably  occurs  with  a  similar  affection  of  the  kidney 
or  prostate,  and  sometimes  with  tuberculosis  of  the  testicle  and 
cord. 

How  is  this  affection  diagnosed? 

The  symptoms  are  those  of  chronic  cystitis,  varying  in  nature 
and  degree  according  to  the  situation  of  the  tubercular  deposit. 
Unless  an  exploratory  instrument  can  detect  the  ulcerated  nodules 
and  inflammatory  thickening  of  the  bladder,  instrumental  examina- 
tion is  negative. 

The  diagnosis  of  this  disease  must  be  mainly  settled  upon  the 
exclusion  of  other  affections,  and  its  coexistence  with  tubercular 
involvement  of  a  neighboring  organ  or  elsewhere.  Examination 
per  rectum  sometimes  reveals  the  characteristic  lumpy  feeling  of  a 
tubercular  vesicula  seminalis  and  the  thickened,  nodular,  indurated 
vas  deferens.  This  or  the  existence  elsewhere  of  the  same  disease 
will  of  course  make  the  diagnosis  probable. 

What  is  the  treatment? 

The  treatment  is  constitutional,  and  the  same  as  when  tuber- 
culosis affects  the  lungs  or  other  parts.  It  is  also  symptomatic, 
varying  according  to  the  amount  of  cystitis  accompanying  it  and 
of  the  pain  which  it  produces. 

What  forms  of  benign  tumors  invade  the  bladder-wall  or  grow 
with  an  attachment  from  it? 

Fibrous  Tumors. — They  appear  only  rarely,  but  occasionally 
single  or  multiple,  growing  from  the  bladder-walls  or  in  the  con- 
nective tissues.  Cysts  are  also  rare,  but  they  occasionally  appear 
here.  They  may  be  simple  cysts  or  dermoids,  when  they  may  contain 
bone,  teeth,  hair,  etc. 

Papilloma  may  also  appear  in  the  bladder  as  perfectly  benign 
growths  or  coming  from  a  cancerous  base.  They  consist  of  villous 
prolongations,  resembling  in  their  appearance  certain  kinds  of  sea- 
weed, and  they  may  occur  in  a  flattened  form  on  the  entire  sur- 
face of  the  bladder,  or  as  a  large  growth,  the  size  of  an  orange  and 
supported  only  by  a  single  pedicle.  There  is  nothing  cancerous 
about  these  tumors  per  se,  and  they  never  lead  to  secondary  can- 
cerous deposits. 


CYSTOSCOPY.  113 

What  forms  of  cancer  are  encountered  in  the  bladder  ? 

The  scirrhous  and  epitheliomatous  are  the  most  common  forms. 
Other  varieties  which  have  been  seen  are  the  encephaloid  and  col- 
loid, etc.  The  malignant  forms  of  tumor  more  commonly  affect  the 
bladder  than  the  benign,  and  are  more  often  an  extension  of  the 
disease  from  elsewhere. 

What  are  the  symptoms  which  accompany  growths  of  the  blad- 
der? 

There  is  not  a  great  deal  of  difference  in  the  symptoms  accom- 
panying the  malignant  and  benign  tumors  of  the  bladder.  There 
is  generally  a  certain  amount  of  cystitis,  varying  according  to  the 
position  and  extent  of  the  tumors,  and  a  certain  amount  of 
obstruction,  due  to  the  position  of  the  growths.  They  are  accom- 
panied by  pain  and  tenesmus,  and  there  is  a  history  of  constant 
oozing  or  intermittent  hemorrhage  from  the  bladder.  Instrumental 
examination  usually  makes  the  symptoms  worse. 

In  determining  the  presence  of  tumors  in  the  bladder,  with  what 
other  affections  may  they  be  confounded? 

Tuberculosis,  stone  in  the  bladder,  and  prostatic  outgrowths. 

Cancer  of  the  bladder  is  more  easily  distinguished  than  other 
tumors.  The  subjective  symptoms  are  more  severe,  the  pain  being 
generally  in  the  back  and  the  thighs,  as  well  as  in  the  perineal 
region  and  over  the  bladder.  The  bleeding  is  apt  to  be  intermit- 
tent, the  hemorrhage  appearing  suddenly  and  profusely,  coming  in 
clots  or  fluid.  Between  these  outbursts  there  is  apt  to  be  more 
or  less  hsematuria.  In  scirrhous  cancer  the  hardness  can  be  felt 
through  the  rectum.  Finally,  the  cachexia  and  the  existence  of 
the  disease  elsewhere  are  important  points  to  be  taken  into  consid- 
eration. Various  conjectures  may  be  made  and  reliable  conclusions 
arrived  at  by  the  use  of  the  searcher  and  the  lithotrite,  but  the 
latest  progress  in  cystoscopy  has  a  more  encouraging  outlook,  and 
the  cystoscope  now  claims  in  practised  hands  to  be  able  to  arrive  at 
conclusions  with  a  greater  rapidity  and  a  greater  certainty  than  has 
ever  before  been  done  by  other  means ;  and  it  seems  as  though  in 
the  hands  of  some  these  claims  have  been  substantiated. 

CYSTOSCOPY. 

What  is  cystoscopy? 

Cystoscopy  is  a  practical  science  involving  the  use  of  an  instru- 
ment termed  the  "  cystoscope,"  which  affords  us  a  means  of  illu- 

8— G-U. 


114  DISEASES   OF   THE   BLADDER. 

minating  the  bladder  and  allowing  the  practised  eye  to  determine 
what  we  have  hitherto  been  compelled  to  detect  by  the  touch  of 
instruments  and  the  examination  of  the  urine.  That  there  is  a 
wide  scope  of  valuable  knowledge  opening  out  for  the  future  of 
the  cystoscopist  there  is  no  doubt,  as  has  been  already  shown  by 
the  results  obtained  by  those  who  in  the  past  have  made  cystoscopy 
a  careful  and  special  study ;  therefore  to  those  who  wish  to  become 
astute  diagnosticians  in  genito-urinary  diseases  it  is  specially  com- 
mended. 

What  does  the  cystoscope  consist  of? 

Briefly,  it  is  made  up  of  a  metallic  tube  with  an  elbow  at  the 
lower  end  leading  to  a  beak.  The  shaft  of  this  instrument  is  about 
7  to  8  inches  long,  and  the  beak  less  than  an  inch.  The  beak  con- 
tains a  small  electric  lamp,  and  the  upper  end,  which  is  called  the 
ocular  portion,  contains  a  switch  which  controls  the  electric  light, 
and  during  use  the  eye  is  placed  at  the  ocular  end  in  order  to  view 
the  interior  of  the  bladder,  which  it  does  through  a  small  prism  sit- 
uated in  the  beak  above  the  electric  light. 

What  special  uses  are  claimed  for  the  cystoscope  in  diagnosis? 

In  the  bladder  it  is  said  to  furnish  the  means  of  affording  a  dif- 
ferential diagnosis  between  the  various  forms  of  catarrh  of  the 
bladder,  to  discover  ulcerations  and  demonstrate  diverticula,  and 
to  reveal  the  presence  of  foreign  bodies,  notably  stones,  whether 
encysted  or  not,  or  tumors,  the  presence  of  which  can  be  discovered 
early  in  their  career.  With  reference  to  kidney  diseases  it  has  been 
used  to  eliminate  vesical  trouble,  thus  locating  the  lesions  in  the  kid- 
ney, and  possibly  distinguishing  which  kidney  is  the  affected  organ. 
Also  the  urine  as  it  exudes  from  the  ureters  may  be  inspected,  and 
its  clear,  purulent,  or  bloody  character  determined.  It  may  also  be 
seen  whether  both  kidneys  are  doing  the  work  or  only  one,  and  the 
amount  of  work  each  is  apparently  doing. 

That  the  practice  of  cystoscopy  requires  ability,  experience,  and 
patience  there  is  no  doubt,  and  it  in  many  cases  becomes  impractica- 
ble, sometimes  on  account  of  the  field  being  obscured  by  an  admixture 
of  blood,  caused  directly  by  the  irritation  of  the  instrument.  There 
has  been  devised  an  "irrigating  cystoscope,"  by  means  of  which  the 
field  may  be  kept  more  clear  by  constant  irrigation.  In  spite,  how- 
ever, of  any  of  the  obstacles  now  existing  in  the  use  of  cystoscopy, 
it  is  even  at  present  a  powerful  aid  to  diagnosis,  involves  a  harm- 


STONE   IN   TRE   BLADDER.  115 

less  examination,  and  often  takes  the  place  of  some  necessarily  more 
serious  operative  exploratory  procedure.  If  in  its  present  immature 
development  cystoscopy  affords  such  valuable  service,  we  may  look 
forward  with  well-founded  hope  for  a  much  wider  field  of  profitable 
research  in  the  future. 

STONE  IN  THE  BLADDER. 
What  are  the  source  and  origin  of  stone  in  the  bladder  ? 

A  great  number  of  the  stones  found  in  the  bladder  are  of  renal 
origin  or  have  as  their  nuclei  a  calculus  which  has  been  derived 
from  the  kidney.  Other  stones  are  formed  primarily  within  the 
bladder,  and  may  have  as  their  nuclei  some  foreign  body,  or  may 
form  as  a  natural  result  of  the  obstruction  to  the  passage  and  con- 
sequent retention  of  urine  in  the  bladder. 

What  are  the  different  constituents  which  go  to  form  a  urinary 
calculus?  • 

It  may  be  formed  of  the  natural  saline  elements  of  the  urine, 
which  are  deposited  in  difi'erent  cases  as  the  salts  of  uric  acid  or 
the  phosphates,  or  of  deposits  which  are  not  constituents  of  the  nor- 
mal urine,  but  separated  from  the  blood  by  the  kidneys  in  certain 
conditions.  Oxalate  of  lime  is  the  most  frequent  constituent  rep- 
resenting this  type,  although  cystine  and  other  more  rare  abnormal 
constituents  of  the  urine  may  occasionally  enter  into  the  formation 
of  calculus.  The  most  frequent  forms  of  calculi  which  are  ordi- 
narily met  with  are  the  uric-acid,  the  phosphatic,  and  the  oxalate- 
of-lime  or  mulberry  calculus.  These  different  forms  may  enter  into 
the  composition  of  the  same  stone,  which  may  have,  for  example,  an 
oxalate-of-lime  nucleus  surrounded  by  urates,  and  finally  encrusted 
with  phosphates,  or  the  latter  may  alternate  in  layers  with  the 
urates ;  such  a  stone  on  section  giving  the  appearance  of  concen- 
tric layers. 

What  are  the  conditions  of  occurrence  of  stone  in  the  bladder? 

Stone  is  more  commonly  met  with  in  advanced  life,  say  after 
fifty.  It  is  next  frequently  met  with  in  early  youth,  and  less 
frequently  in  middle  age.  It  is  far  more  frequent  in  males  than  in 
females,  and  is  generally  more  frequently  met  with  in  cold  than  in 
warm  climates.  In  certain  portions  of  the  same  country  it  would 
seem  to  exist  in  greater  frequency  than  in  others,  while  in  certain 
places  there  is  a  greater  prominence  of  one  kind  of  calculus  than 


116  DISEASES   OF   THE   BLADDER. 

anotlier.  There  also  seems  to  be  a  greater  prevalence  amongst 
those  leading  a  sedentary  life  than  among  the  working  and  active 
laborers  and  mechanics. 

What  is  probably  the  most  common  form  of  urinary  calculus  ? 
Uric  acid. 

What  is  the  general  course  of  its  formation  ? 

It  is  generally  derived  from  a  pre-existing  "  gravel,"  which  may 
exist  as  a  persistent  "  brick-dust"  deposit  (excess  of  urates),  or  from 
a  conglomeration  of  uric-acid  crystals  passed  in  masses  from  the 
kidney,  which  may  vary  in  size  from  a  small  crumb  to  the  size  of 
a  pea.  The  bladder  may  expel  the  calculus  through  the  urethra 
before  it  has  reached  a  size  too  large  to  be  passed ;  but  if  this  does 
not  occur,  the  stone  increases  in  bulk  by  the  deposit  on  its  surface 
of  more  urates  or  phosphates,  and  may  in  the  course  of  time 
become  a  very  formidable  affair. 

What  is  the  course  of  formation  of  a  phosphatic  calculus  ? 

A  phosphatic  calculus  is  not  apt  to  be  formed  in  the  kidney, 
and  is  most  commonly  a  concomitant  or  the  result  of  pre-existing 
bladder  disease.  Any  cause  which  produces  an  obstruction  to  the 
bladder  or  interferes  with  the  natural  emptying  of  its  contents  may 
be  indirectly  the  cause  of  a  urinary  calculus,  and  therefore  the 
phosphatic  stone  or  deposits  from  decomposed  urine  is  most  frequent 
in  the  aged,  whereas  the  uric  acid  is  generally  found  in  the  young. 
The  former  is  soft  and  alkaline,  the  latter  is  hard  and  acid.  The 
oxalate-of-lime  calculus  forms  in  the  kidney  first,  like  the  uric-acid 
stone.  It  is  the  hardest  in  structure,  and  more  difficult  to  remove 
than  any  other  on  account  of  its  hardness  and  its  rough  and  uneven 
surface. 

What  conditions  are  necessary  for  the  formation  of  a  urinary 
calculus  ? 

(1)  A  diathesis  involving  a  predisposition  to  the  excessive 
deposit  of  certain  normal  or  abnormal  urinary  constituents,  which 
is  influenced  by  diet,  habits,  etc. :  or  (2)  an  interference  with  the 
natural  passage  of  the  urine,  involving  decomposition  and  deposit 
of  phosphatic  material ;  (3)  the  existence  of  a  colloid  or  cement 
material  for  the  agglutination  of  the  calcareous  material.  This 
may  be  formed  by  the  mucus  and  pus  furnished  in  kidney  or 
bladder  disease. 


STONE    IN    THE    BLADDER.  117 

What  is  the  general  shape  of  urinary  calculi? 

They  are  generally  oval  or  rounded  with  flat  surfaces.  The 
surface  may  be  smooth,  but  is  generally  rough,  notably  in  the  case 
of  oxalate-of-lime  calculi. 

What  is  the  general  size  ? 

They  may  be  any  size,  from  a  small  renal  calculus  upward. 
One  the  size  of  a  hickory-nut  may  be  called  small.  Anything 
above  an  inch  in  diameter  would  be  considered  large.  They  vary 
in  weight  according  to  size,  and  may  weigh  anywhere  from  a  few 
grains  up  to  fifty  ounces  or  possibly  more.  They  may  be  single  or 
multiple. 

How  is  a  stone  properly  examined  chemically? 

It  should  first  be  sawed  through  the  centre  in  equal  halves,  so 
as  to  display  the  concentric  layers,  which  must  be  separately  tested. 
It  must  then  be  examined  for  its  organic  and  inorganic  constituents. 
If  it  consists  largely  of  organic  material,  it  may  be  determined  by 
burning  a  small  portion  in  the  Bunsen  burner,  by  which  it  will  be 
almost  entirely  consumed.  If,  then,  this  be  determined  and  the 
organic  material  be  uric  acid^  its  presence  will  be  detected  by  dis- 
solving a  small  portion  of  the  powder  in  dilute  nitric  acid  upon  a 
porcelain  dish,  dry  over  a  spirit  lamp,  and  then  leave  it  to  cool. 
This  will  leave  a  yellowish-red  sediment,  and  by  waving  a  glass  rod 
moistened  with  ammonia  close  to  the  sediment  a  beautiful  purple- 
red  will  develop.  This  is  the  murexid  test.  If  it  be  vrate  of 
ammonia,  it  will  be  dissolved  by  boiling  some  of  the  powder  in 
water,  and  if  it  be  boiled  with  liquor  potassse  the  fumes  of  ammonia 
are  given  off,  and  a  rod  moistened  in  acetic  acid  will  produce  white 
fumes.  If  this  test  fails  and  the  calculus  is  still  deemed  organic 
and  not  inorganic,  xanthine  may  be  discovered  by  dissolving  the 
powder  in  dilute  nitric  acid  and  drying  slowly  with  a  spirit  lamp  in 
a  porcelain  dish.  This  leaves  a  bright-yellow  color  which  is  not 
changed  by  ammonia,  but  becomes  reddish-yellow  on  the  application 
of  a  drop  of  liquor  potassae.  If  the  organic  material  be  cystine,  in 
burning  the  powder  on  a  platinum-foil  wire  disagreeable  sulphurous 
odors  will  be  emitted,  and  the  same  powder  in  alkaline  solution 
allowed  to  evaporate  will  show  characteristic  crystals.  If,  however, 
in  burning  a  portion  of  the  calculus  a  considerable  residue  remains, 
it  is  composed  largely  of  inorganic  constituents  or  of  the  organic 
salts,  such  as  urate  of  potash,  sodium,  lime,  or  magnesium,  and  the 
oxalate,  carb(mate,  or  phosphate  of  lime  or  the  ammonio-magnesium 


118  DISEASES   OF  THE   BLADDER. 

phospliate.  The  murexid  test,  if  applied  to  the  powder  before 
burning,  shows  the  presence  of  uric  acid,  but  the  presence  of  a 
substantial  residue  after  the  heating  proves  the  existence  of  uric 
acid  in  combination  with  an  earthy  base.  If  the  murexid  test  fails 
on  the  powder,  it  may  be  oxalate  of  lime,  and  to  determine  this  a 
portion  of  it  should  be  put  upon  a  piece  of  charcoal  and  treated 
with  the  blowpipe.  At  first  the  red  heat  blackens  it,  and  later 
whitens  it,  when  it  becomes  a  carbonate  of  lime,  which  dissolves  in 
dilute  acids  with  efi'ervescence.  White  heat  reduces  the  powder  to 
caustic  lime,  which  is  insoluble  in  the  dilute  acids  with  efferves- 
cence. Oxalate  of  lime  before  treated  with  the  blowpipe  is  un- 
affected by  acetic  acid,  and  it  dissolves  in  mineral  acids  without 
effervescence. 

To  distinguish  the  remaining  substances,  dissolve  some  of  the 
powder  in  hydrochloric  acid.  It  either  effervesces  or  not.  If  it 
does,  it  is  either  carbonate  of  lime  or  magnesium.  If  it  does  not 
effervesce,  it  is  either  oxalate  of  lime  or  phosphates. 

What  are  the  symptoms  of  stone  in  the  bladder? 

Frequency  of  micturition,  relatively  greater  by  day  than  at  night, 
increased  by  exercise,  pain  at  the  end  of  the  penis  and  at  its  under 
surface,  generally  felt  during  the  act  of  urination  and  after  it  is 
finished.  The  condition  of  the  urine  is  generally  striking.  It  is 
almost  always  a  condition  of  cloudy  urine,  loaded  with  pus  and 
mucus,  and  perhaps  with  a  certain  amount  of  calcareous  deposit  or 
gravel,  and  almost  invariably  the  patient  will  give  a  history  of 
having  passed  blood  some  time  during  the  course  of  his  symptoms. 
If  this  latter  symptom  exists  more  or  less  constantly,  it  is  in- 
creased by  exercise. 

What  is  the  proper  manner  of  examining  a  patient  with  sus- 
pected stone  in  the  bladder? 

A  short  curved  steel  instrument  should  be  adopted,  imitating 
the  curve  of  the  instrument  of  Thompson,  as  shown  in  Fig.  10. 
Any  ordinarily  curved  sound  or  catheter  will  not  suffice  always  to 
detect  the  presence  of  the  stone.  This  instrument  is  possessed  of 
a  short  curve,  as  a  result  of  which,  when  introduced  into  the  blad- 
der, it  can  be  easily  rotated  from  side  to  side,  and  the  inside  of  the 
bladder  be  carefully  searched  in  a  systematic  manner  by  its  means. 
In  the  hands  of  an  experienced  operator  it  is  not  only  possible  to 
determine  the  presence  of  a  stone  by  this  instrument,  but  also  ap- 


STONE   IK   THE   BLADDER.  119 

proximately  the  size  and  its  consistency.  The  general  characteristics 
of  the  different  stones  should  be  borne  in  mind.  The  phosphatic 
is  soft,  the  uric-acid  hard,  the  mulberry  calculus  rough  and  uneven. 
It  is  difficult  to  distinguish  in  the  bladder  between  a  mulberry  and 
a  uric-acid  calculus.  However,  the  different  symptoms  accompany- 
ing regularly  the  different  kinds  of  stone  will  aid  in  determining 
the  nature  of  a  given  stone.  That  removal  of  an  existing  stone 
is  the  only  course  of  treatment  to  be  pursued  there  is  no  doubt ; 
the  only  question  which  arises  is  the  choice  of  the  means  for  its 
extraction. 

What  are  the  different  operative  procedures  advised  for  the  ordi- 
nary treatment  of  stone  in  the  bladder  ? 

Lithotomy,  lithotrity,  and  litholapaxy  (simply  rapid  lithotrity). 

What  is  lithotomy? 

Lithotomy  is,  briefly,  the  operation  of  cutting  for  stone  in  the 
bladder — an  operation  which  was  performed  in  the  Middle  Ages. 
and  which  probably  has  existed  ever  since  surgery  first  attempted 
to  offer  any  means  of  relief  to  suffering  humanity. 

What  is  lithotrity  ? 

Lithotrity  is  that  procedure  by  means  of  which  a  stone  in  the 
bladder  is  crushed  and  the  fragments  removed  by  means  of  a  wash- 
ing-tube passed  through  the  urethra. 

What  is  to  guide  us  in  the  choice  of  operation  for  this  condition  ? 

No  invariable  rule  may  be  laid  down.  It  simply  may  be  said 
that  statistics  show  that  the  female  tolerates  the  cutting  operation 
better  than  the  male,  and  the  child  much  better  than  the  adult. 
Since  the  advent  of  litholapaxy  there  has  been  very  little  doubt  as 
to  the  choice  of  operation  for  the  removal  of  stone  in  those  whose 
symptoms  are  entirely  derived  from  this  one  source  :  in  those  who 
have  also  an  hypertrophied  and  interfering  prostatic  enlargement, 
where  removal  of  a  stone  may  only  partially  allay  the  symptoms, 
the  recently  increased  practice  of  the  superpubic  cutting  operation 
has  brought  this  procedure  forward  as  an  important  consideration 
in  the  choice  of  a  treatment  for  urinary  calculi.  In  general 
terms  it  may  be  said  that  litholapaxy  is  the  operation  to  be  re- 
sorted to  in  the  majority  of  cases,  the  exceptions  being  possibly  in 


120 


DISEASES   OF  THE   BLADDER. 


extreme  youth,  in  cases  where  the  stone  is  too  hard  to  be  crushed, 
and  in  those  cases  where  an  enlarged  prostate  coexists  with  the 
stone,  where  it  may  be  deemed  more  expedient  to  adopt  an  opera- 
tion which  will  also  allow  of  the  removal  of  a  portion  of  the  offend- 
ing prostate. 

What  instruments  are  essential  for  the  proper  performance  of 
the  operation  of  lithotrity  ? 

First  the  lithotrite  or  crusher,  and  second,  the  evacuator  or  ap- 
paratus used  for  washing  out  the  crushed  fragments  of  the  stone. 
The  lithotrite  of  the  present  day  consists  of  two  blades  curved  at 
about  the  same  degree  as  the  searcher,  one  of  which  fits  within  the 
other,  so  that  when  closed  the  appearance  of  having  one  blade  only 
is  given,  and  when  open  it  allows  the  stone  to  be  taken  within  the 
grasp  of  the  two  blades.  The  larger  blade  is  called  the  male  blade, 
and  the  one  which  fits  within  the  other  the  female  blade.  Crushing 
is  effected  by  a  rack  and  pinion  at  the  other  end  of  the  instrument, 
and  a  button  is  on  the  side  of  the  instrument,  so  that  when  turned 
in  one  direction  the  blades  are  entirely  controlled  by  a  screw  move- 
ment, and  when  turned  in  the  other  direction  it  releases  the  shaft 
of  the  instrument,  and  the  blades  may  be  opened  and  shut  by 
moving  the  shaft  in  or  out.     Figs.  12,  A,  B,  and  C 

There  are  several  kinds  of  evacuating  or  washing  instruments : 
probably  the  most  useful  one  is  the  latest  device  of  Bigelow.     It 


Lithotrite. 


consists  of  a  rubber  bag  for  suction,  underneath  which  is  a  hollow 
glass  bulb,  so  that  when  the  washer  is  attached  to  a  steel  tube  which 


STONE   IN   THE   BLADDER. 


121 


Fig.  12,  B. 


Fig.  12,  C 


Lithotrite. 


Lithotrite  Separated. 


122  DISEASES   OF   THE   BLADBEH. 

has  been  introduced  into  the  bladder,  by  a  gentle  and  regular  pres- 
sure on  the  bulb,  which  is  filled  with  water,  the  contents  may  be 
thrown  into  the  bladder,  and  in  turn  sucked  back  again  into  the 
instrument,  carrying  with  it  the  fragments  of  the  broken  stone, 
which  as  a  result  of  gravity  fall  down  into  the  glass  bulb  and  may 
be  seen  by  the  operator.  The  evacuating  tubes  are  of  various  kinds, 
straight  and  curved,  to  be  used  as  the  occasion  requires.  They  are 
made  of  thin  metal,  so  that  the  calibre  may  take  up  as  near  the 
full  size  of  the  instrument  as  possible. 

What  is  litholapaxy  ? 

Rapid  lithotrity,  in  which  the  operation  is  performed  at  one 
sitting.  It  was  formerly  customary  to  remove  the  fragments  of 
stone  in  the  bladder  at  several  different  sittings.  It  was  first  pro- 
posed by  Professor  Bigelow,  and  since  then  it  is  probably  the  only 
crushing  operation  that  is  generally  employed. 

Is  there  any  preparation  of  the  patient  prior  to  the  operation  of 
lithotrity  ? 

Besides  the  general  preparation  of  a  patient  for  the  anaesthetic, 
it  is  well  to  resort  to  the  same  measures  as  in  other  urethral  opera- 
tions— namely,  the  use  of  salol  twenty-four  to  forty-eight  hours 
before  the  operation,  and  diuretin  twelve  hours  before,  to  be  kept 
up  until  the  kidneys  are  to  be  relied  upon. 

What  are  the  steps  in  the  operation  of  litholapaxy  ? 

The  patient  is  in  a  recumbent  posture  and  under  the  influence  of 
an  anaesthetic.  A  firm  flat  pillow  should  be  placed  under  the  pel- 
vis of  the  patient  in  order  to  facilitate  the  exploration  of  the  blad- 
der. If  the  meatus  is  congenitally  small,  it  must  be  cut  to  allow 
the  passage  of  the  instruments  and  a  proper-sized  tube.  It  is  well 
to  have  a  certain  amount  of  fluid  in  the  bladder,  as  the  stone  can 
be  more  readily  grasped  when  the  bladder  is  not  collapsed.  Hav- 
ing introduced  the  lithotrite,  we  first  endeavor  to  catch  the  stone, 
for  which  purpose  the  blades  are  opened  and  closed  in  an  area  in 
which  the  stone  is  expected  to  exist ;  and  when  it  is  clasped  within 
the  grasp  of  the  blade,  the  button  which  reverses  the  action  of  the 
handle  is  pushed  and  the  wheel  at  the  end  is  turned  until  the  en- 
gaged body  is  crushed.  The  first  crushing  results  in  a  separation 
of  the  stone  into  several  difierent  pieces,  each  of  which  has  to  be 
partly  crushed,  until  the  fragments  are  presumably  small  enough 


STONE   IK   THE   BLADDER. 


123 


to  be  washed  out  through  the  evacuating  tube.  After  a  certain 
amount  of  crushing  has  been  done  the  instrument  is  removed  and  a 
washing-tube  introduced,  and  all  fragments  which  are  small  enough 

Fig.  13,  A. 


Bigelow's  Evacuator. 


to  pass  through  its  lumen  are  washed  out  by  the  evacuator 
(Fig.  13,  A),  The  lithotrite  is  again  resorted  to  for  the  purpose  of 
catching  and  crushing  the  remaining  fragments.  The  chano-e  of 
hthotrites  from  one  kind  to  another  is  deemed  advisable  a's  the 
circumstances  may  require.  (See  Fig.  12,  A,  B,  C.)  In  general 
an  instrument  with  heavy  blades  and  fenestrated  female  blade  is 
used  in  the  start  when  the  stone  is  at  all  hard.  As  the  operation 
progresses  a  lighter  instrument  may  be  used,  either  fenestrated  or 
one  which  has  a  spoon-shaped  female  blade  inside.  By  this  latter 
instrument  a  more  thorough  pulverization  of  the  fragments  may 
be  effected.  As  the  operation  draws  to  a  close  and  there  is  doubt 
as  to  the  existence  of  further  fragments,  the  washing  apparatus 


124 


DISEASES   OF   THE   BLADDER. 


Fig.  13,  B. 


Evacuating  Tube. 


should  be  introduced :  then,  having  an  assistant 
place  his  ear  over  the  abdomen,  by  causing  a  sharp 
action  of  the  evacuator  the  click  of  fragments, 
if  there  be  any,  may  be  heard  by  him.  In  this 
manner  the  operation  may  be  persistently  pur- 
sued until  all  trace  of  the  stone  is  removed  ;  but 
if  it  has  occupied  an  unduly  long  time,  and  it  is 
undesirable  to  continue  the  anaesthetic,  it  is  well 
to  wait  until  another  time,  when  a  possibly  re- 
maining fragment  may  be  removed. 

What  is  the  after-treatment  in  these  cases? 

The  after-treatment  is  simply  that  of  a  mild 
cystitis,  and  is  palliative. 

What  complications  are  likely  to  accompany 
this  operation? 

Impaction  of  a  fragment  in  the  urethral  ori- 
fice. Long  urethral  forceps,  as  shown  in  Fig.  11, 
have  been  devised  for  the  purpose  of  the  removal 
of  a  small  impacted  stone  in  the  urethra  and 
the  impacted  fragments.  If,  however,  the  stone 
is  thoroughly  crushed  at  the  time  of  the  opera- 
tion there  will  be  little  danger  of  this  complica- 
tion, unless  a  fragment  gets  caught  in  the  eye 
of  the  washing-tube,  as  it  occasionally  does. 

Severe  cystitis  is  sometimes  a  complication, 
occurring  after  this  operation  about  the  fourth 
or  fifth  day,  when  it  may  set  in  without  appa- 
rent notice  or  reason.  To  lessen  the  liability 
of  its  occurrence  perfect  quiet  in  the  recum- 
bent position  should  be  strictly  enjoined.  Ure- 
thral fever  may  also  occur  as  a  result  of  the 
impression  made  by  this  operation.  Its  occur- 
rence is  probably  best  avoided  by  the  use  of 
diuretin  and  careful  antisepsis.  Bleeding,  though 
sometimes  occurring,  is  infrequently  of  a  trou- 
blesome nature,  and  therefore  does  not  require 
treatment. 

What  is  the  condition  of  the  patient  after  the 
removal  of  stone  in  the  bladder  ? 


In  the  majority  of  cases  there  is  a  freedom  from  all  symptoms 


STONE    IN    THE    BLADDER. 


125 


and  an  immunity  from  reappearance  of  the  calculus  ;  but  there  are 
a  certain  number  of  cases  in  whom  the  stone  reappears,  and  in 
those  in  whom  this  condition  recurs  there  is  either  an  existing 
diathesis  (a  strong  tendency  to  the  production  of  uric  acid),  or, 
from  the  presence  of  an  hypertrophied  prostate,  there  is  an  ab- 
normal evacuating  power  of -the  bladder,  and  the  consequent  con- 
tinual retention  of  decomposed  and  alkaline  urine  reproduces  the 
conditions  which  produced  and  increased  the  formation  of  the 
original  calculus.  If  proper  means  are  not  adopted  to  remove  or 
counteract  these  conditions,  there  will  be  a  new  calcareous  deposit. 

What  other  method  is  resorted  to  for  the  extirpation  of  stone 
in  the  bladder? 

Lithotomy  or  the  cutting  operation.     Of  the  perineal  operations 

there   are  principally  two,   the   lateral  and   the  median,     xlll   the 

others  are  simply  modifications  of  either  of   these.     The   "  high 

operation,"   or   suprapubic   lithotomy,  is   opening    of   the   bladder 

above  the  pubis  for  this  purpose,  and  is  conducted  practically  in  the 

same  manner  as  in  performing  a  prostatectomy. 

What  are  the  steps  in  a  lateral  perineal  lithotomy? 

The  patient  having  been  anaesthetized  and  put  in  the  lithotomy 
position,  a  good-sized  staff  is  introduced,  possessing  a  wide  groove. 
An  incision  is  made  about  one-third  of  an  inch  to  the  left  side 
of  the  raphe  and  about  an  inch  and  a  half  in   front  of  the  anus. 

Fig.  14,  A. 


Stone  Forceps. 

and  carried  obliquely  outward.  The  knife  should  be  introduced 
steadily  in  the  direction  of  the  staff.  Having  made  a  fairly  deep 
wound,  the  index  finger  of  the  left  hand  being  in  the  rectum,  find 
the  groove  of  the  staff  with  the  point  of  the  knife,  and  when 
found  run  the  instrument  steadily  on  in  contact  with  the  staff. 
dividing  a  portion  of  the  prostate.     Cut  in  an  outward  direction, 


126 


DISEASES   OF  THE   BLADDER. 


and  keep  the  point  of  tlie  instrument  continually  in  the  groove. 

After  reaching  the  bladder  a  pair  of  stone  forceps  (see  Figs.  14,  A, 
14  -D  ^^^  I'^j  ^)  ^^6  introduced,  and 

'     ■  the  stone  seized  in  its  shortest 

diameter.  Extraction  should 
be  slow.  After  removing  the 
stone  the  bladder  should  be 
searched  for  the  possible  ex- 
istence of  another  stone.  If 
the  stone  be  encysted  or  fixed, 
it  takes  a  good  deal  of  care 
and  work  to  remove  it.  If  it 
be  deeply  encysted,  it  may  be 
impossible. 

The  stone  extracted  should 
be  examined  for  facets  denot- 
ing contact  with  another  stone 
or  stones.  If  it  be  found  to 
be  smooth  and  rounded,  there 
is  probably  no  other  present. 

Does  hemorrhage  often  occur 
during  the  operation? 

Yes,  but  it  is  rarely  profuse. 
If  it  is  severe,  it  is  well  to  use 
a  tent,  such  as  is  used  in  peri- 
neal section. 

What  is  the  after-treatment 
of  perineal  lithotomy  ? 

The  treatment  is  practically 
the  same  as  after  an  ordinary 
perineal  section,  the  bladder 
being  washed  according  to  the 
amount  of  the  existing  cystitis 
or  the  presence  of  blood  in  the 
urine. 

What  is  the  bilateral  opera- 
tion? 

Suitable  for  large  stones,  it 
differs  from  the  lateral  in  hav- 
ing a  semilunar  external  incision  across  the  raphe  about  one  inch  in 


stone  Forceps. 


STONE   IN   THE   BLADDER.  127 

front  of  the  anus,  dividing  the  skin,  cellular  tissue,  and  some  fibres 
of  the  sphincter  ;  and  when  this  wound  is  opened  the  muscular 
fibres  which  attach  the  bulb  of  the  urethra  down  to  the  rectum  are 
divided  and  an  opening  made  through  the  membranous  urethra. 
At  this  point  an  instrument  termed  the  double  lithotome  cache  is 

Fig.  15. 


Fenestrated  Forceps. 

introduced.  Its  point,  being  placed  in  the  groove  of  the  stafi",  is 
guided  into  the  bladder,  the  staff  withdrawn,  and  the  hidden  blades 
of  the  lithotome  protrude.  The  instrument  is  then  withdrawn,  and 
the  stone  is  extracted  as  in  the  lateral  operation. 

How  is  the  median  operation  classically  distinguished? 

It  is  known  as  the  Marian  operation. 

What  is  its  special  indication  ? 

It  is  adaptable  for  small  stones  and  in  children  where  the  crush- 
ing operation  is  not  deemed  advisable. 

How  does  the  operation  differ  from  the  lateral? 

The  steps  in  the  operation  are  practically  the  same,  the  instru- 
ment being  a  staff  similar  to  the  one  used  in  the  lateral  operation, 
except  having  a  groove  in  the  centre  instead  of  on  the  side.  The 
primary  incision  is  made  in  the  median  line  of  the  perineum,  and 
the  bladder  is  reached  in  a  manner  similar  to  external  perineal 
urethrotomy.  Where  the  prostrate  is  enlarged  curved  forceps  are 
required  to  overreach  it  in  extracting  the  stone.     (See  Fig.  15.) 

"What  are  the  other  operations  for  perineal  lithotomy? 

They  are  only  modifications  of  the  median  operation,  and  differ 
from  it  in  the  prostatic  incisions,  which  are  made  on  one  or  both 
sides. 

What  is  the  anatomy  of  the  perineum,  as  important  to  know  in 
the  performance  of  perineal  lithotomy  ? 

It  relates  particularly  to  those  structures  contained  in  the  tri- 
angle bounded  on  either  side  by  the  bony  wings  of  the  pubis  and 


128 


DISEASES   OF   THE   BLADDER. 


ischium,  and  a  line  drawn  in  front  of  the  anus  which  connects  these 
two  sides  of  the  triangle  and  represents  its  base. 

What  are  the  coverings  of  this  space  ? 

Integument,  superficial  fascia,  which  corresponds  to  the  super- 
ficial fascia  elsewhere  in  the  body,  spoken  of  here  as  the  superficial 
layer  of  the  superficial  fascia,  the  deep  layer  of  the  superficial  fascia, 
which  is  often  called  the  superficial  perineal  fascia.  These  are  named 
in  contradistinction  to  the  deep  perineal  fascia  or  triangular  ligament. 

What  are  the  structures  necessarily  divided  in  the  lateral  opera- 
tion? 

Perineal   integument,    superficial    fascia    (superficial    and   deep 

Fig.  16,  A. 


AfiterltrXay^r  of 
Deep.  Tirinewl  T^a-scia  TemovctL 
Shervinff 


COMPJtESSOR     URETHRiB 

Jniernal  Pudio^Art  y. 
Contpe-^t  Gland' 


Deep  Perineal  Fascia  (Gray). 


sto:ne  in  the  bladder. 

Fig.  16,  B. 


129 


Ccwpef/'g  GlaTid- 


Ajfteru  of  Carpus  Cavernosum 
Dorsal  Arter^  of  Penis 


Artery  of  £ul6, 
Xntcj^nal  J'uctlc  Artery 


Viscera  at  Outlet  of  Pelvis  (Gray). 

layers),  superficial  vessels  and  nerves  (inferior  hemorrhoidal),  the 
posterior  portion  of  the  accelerator  uringe  muscle  ;  superficial  peri- 
neal vessels  and  nerves ;  the  transverse  perineal  muscle  and  the 
artery  ;  the  two  layers  of  the  deep  perineal  fascia  ;  perhaps  the 
anterior  edge  of  the  levator  ani ;  the  membranous  urethra  and  its 
muscular  covering ;  the  compressor  urethras  ;  the  prostatic  urethra, 
including  a  part  of  the  neck  of  the  bladder  and  a  portion  of  the 
prostate. 

What  are  the  structures  to  be  avoided? 

In  front,  the  bulb  and  its  artery  ;  behind  and  toward  the  median 
line,  the  rectum  ;  externally,  the  pudic  artery. 

9— G-U. 


130  DISEASES   OF   THE  UEETERS. 

What  are  the  complications  of  perineal  lithotomy  ? 

Inflammation  in  the  tissues  around  the  neck  of  the  bladder ;  in- 
filtration ;  retention  ;  secondary  hemorrhage  ;  septicaemia  ;  pyaemia  ; 
erysipelas,  more  unusually  tetanus,  and  extreme  hemorrhage  accom- 
panying the  hemorrhagic  diathesis  or  where  the  arterial  distribution 
in  the  perineal  space  is  anomalous,  there  being  an  accessory  pudic 
artery  ;  and  finally  peritonitis  sometimes  occurs. 

What  are  some  of  the  unpleasant  after-effects  ? 

Fistulae ;  incontinence,  temporary  and  sometimes  permanent ; 
sterility  where  both  vasa  deferentia  have  been  cut ;  epididymitis 
following  an  operation  involving  the  prostate ;  severe  cystitis  when 
the  bladder  has  been  subjected  to  much  mechanical  violence ;  and 
acute  kidney  outbreaks  on  top  of  a  pre-existing  chronic  condition. 

What  conditions  contribute  to  cause  a  relapse  of  stone  ? 

The  uric-acid  diathesis  when  proper  attention  to  diet  is  not 
observed  in  the  case  of  uric-acid  stone ;  insufficient  evacuation  of 
the  debris,  leaving  behind  a  fragment  of  the  stone,  and  in  the  case 
of  a  phosphatic  stone,  where  an  obstructive  prostate  exists,  improper 
washing  of  the  bladder  after  the  operation  may  result  in  the  forma- 
tion of  another  stone.  When  this  condition  exists,  it  is  therefore 
desirable  to  consider  the  expediency  of  the  suprapubic  operation,  in 
order  that  a  prostatectomy  may  also  be  done  at  the  time  of  the 
removal  of  the  stone. 

A  suprapubic  lithotomy  is  conducted  in  the  same  manner  as  the 
suprapubic  operation  for  removal  of  an  obstructing  prostate. 

DISEASES  OF  THE  URETERS. 

Give  the  anatomy  and  function  of  the  ureters. 

They  are  excretory  ducts  of  the  kidneys,  and  run  behind  the 
peritoneum  from  the  pelvis  of  the  kidney  over  the  brim  of  the 
bony  pelvis  to  the  base  of  the  bladder  on  either  side,  lined  inter- 
nally by  a  mucous  membrane  surrounded  by  unstriped  muscular 
fibres,  longitudinal  and  circular,  bound  together  by  connective 
tissue. 

Name  the  anomalies  of  the  ureter. 

Double  and  triple  ureter,  which  may  exist  the  entire  length  of 
the  canal ;  ureter  on  one  side  only  or  ending  on  one  side  in  a  blind 
extremity,  in  which  case  the  kidney  atrophies. 


DISEASES   OF   THE   KIDNEY.  131 

Describe  the  affections  of  the  ureter. 

Granular  inflammation  may  ascend  to  the  ureter  from  the  blad- 
der or  descend  from  the  pelvis  of  the  kidney.  Distension  of  one 
portion  of  the  ureter  may  occur  from  pressure  of  a  tumor  or  from 
an  enlargement  of  a  kidney-stone.  Stricture  may  be  caused  by 
a  calculus  after  its  passage.  Tuberculous  and  cancerous  diseases 
may  also  involve  the  ureter.  Anything  which  causes  obstruction 
of  the  ureter  produces  hydronephrosis. 

DISEASES  OF  THE  KIDNEY. 

What  is  the  anatomy  of  the  kidney  ? 

There  are  normally  two  kidneys,  one  on  either  side,  situated  in 
the  lumbar  region,  high  up,  extending  nearly  to  the  crest  of  the  ilium 
on  either  side  of  the  spinal  column,  shaped  like  the  so-called 
"  kidney  bean,"  with  its  convexity  turned  inward.  They  are 
enveloped  in  a  dense  fibrous  capsule  or  envelope  and  surrounded 
by  fat.  The  healthy  kidney  weighs  from  4  to  6  ounces.  In  its 
anatomical  structure  the  kidney  is  divided  into  a  cortical  and 
pyramidal  portion.  The  cortical  is  the  external  and  secreting  por- 
tion, and  contains  the  convoluted  uriniferous  tubes  and  Malpighian 
bodies.  The  pyramidal  or  medullary  portion  is  formed  by  con- 
verging straight  tubes,  which  unite  with  the  convoluted  tubes  in 
the  cortical  portion.  The  pyramids  dip  into  the  cavity  of  the 
kidney,  called  the  sinus,  where  they  terminate  in  "  papillge,"  each 
of  which  is  surrounded  by  a  little  cup-like  cavity,  the  calyx,  and 
all  the  calyces  unite  to  form  the  pelvis,  which  communicates  with 
the  ureter. 

ANOMALIES. 

There  is  sometimes  only  one,  occasionally  two,  three,  or  more. 
They  are  sometimes  united  above,  resembling  a  horseshoe  in  shape. 
A  loosely-connected  kidney  may  become  displaced  in  the  abdomen 
and  freely  movable,  forming  the  so-called  floating  kidney,  the  result 
of  undue  exercise  or  in  females  tight  lacing,  or  it  may  be  dis- 
placed into  the  cavity  of  the  bony  pelvis. 

In  what  different  ways  do  affections  of  the  kidneys  show  them- 
selves ? 

By  subjective  symptoms,  such  as  pain,  constant  and  intermit- 
tent, localized  in  the  kidney  region,  running  down  the  ureters,  up 
the  back,  and  down  the  thighs ;  pain  on  pressure  in   the  kidney 


132  DISEASES   OF   THE   KIDNEY. 

region  ;  by  external  local  evidences  felt  on  examination,  such  as 
enlargements  and  displacements ;  by  evidences  shown  by  impair- 
ment of  the  urinary  function  ;  and  by  an  abnormal  condition  of  the 
urine. 

RENAL  CALCULUS. 

Where  may  renal  calculus  originate  ? 

In  the  uriniferous  tubes  or  in  one  of  the  calyces  of  the  kidneys 
or  in  the  pelvis.  They  may  be  dislodged  from  this  situation  and 
pass  into  the  bladder,  causing  the  symptoms  of  urinary  calculi 
during  their  course,  or  they  may  remain  and  enlarge  in  their  orig- 
inal site,  where  they  may  or  may  not  give  rise  to  symptoms,  and 
are  not  to  be  discovered  until  after  death. 

What  are  the  most  common  forms  of  renal  calculus  ? 

Uric  acid  first,  and  next  oxalate  of  lime.  Other  renal  calculi 
found  are  the  carbonate  and  phosphate  of  lime,  the  ammonio-mag- 
nesium-phosphate,  cystine,  xanthine,  and  the  mixed  urates,  any  of 
which  may  form  the  starting  focus  or  nucleus  of  a  stone  or  may  be 

its  sole  constituents. 

What  is  the  etiology  of  renal  calculi  ? 

They  are  the  deposit  of  excess  of  normal  or  abnormal  con- 
stituents of  the  urine.  They  may  develop  in  any  period  of  life, 
and  affect  both  kidneys  or  only  one ;  they  may  be  single  or  multi- 
ple in  one  or  both  kidneys.  There  are  numerous  variations  in  size 
and  shape,  from  that  of  a  pea,  smooth  and  round,  to  the  picture 
presented  in  Fig.  17  of  a  conglomeration  of  kidney-stone  extracted 
by  Dr.  Keyes. 

What  are  the  symptoms  accompanying  renal  calculi? 

The  symptoms  depend  largely  upon  the  position  in  which  the 
calculus  or  calculi  are  lodged,  and  upon  the  size  :  one  stone  may  be 
large  and  rough  and  may  remain  in  an  unoffending  condition,  lodged 
in  one  of  the  calyces,  without  giving  rise  to  any  outward  mani- 
festations of  disease,  being  the  cause  of  only  slight  chronic  inter- 
stitial inflammation.  A  very  small  stone  lodged  in  one  of  the 
uriniferous  tubes  may  excite  acute  inflammation.  Stones  situated 
in  the  pelvis,  lodged  over  the  opening  of  the  ureter,  may  lead  to 
chronic  inflammation  and  dilatation,  or  pyelitis  or  nephritis,  and 
abscess  involving  a  portion  or  the  whole  of  the  kidney  structure. 
Those  symptoms  which  accompany  stone  in  the  kidney  with  va- 
riable severity  are  lumbar  pain,  increased  on  exercise ;  some  blad- 


EENAL  CALCULUS.  .  133 

der  irritability ;  pus,  mucus,  or  albumin  found  in  the  urine  in 
moderate  or  marked  quantities,  and  blood,  sometimes  in  large 
quantities,  for  periods  of  several  days,  at  other  times  entirely  ab- 

FiG.  17. 


Eenal  Calculus. 

sent;  added  to   which  the  patient  may  from  time  to  time  pass 
gravel  or  calcareous  material. 

What  is  the  so-called  renal  colic  ? 

Renal  colic  is  caused  by  the  passage  of  a  calculus  large  enough 
to  stretch  unduly  the  tissues  of  the  ureter.  It  comes  on  suddenly 
and  subsides  suddenly,  and  has  a  variable  duration,  from  periods  of 
an  hour  or  less  to  several  days.  The  position  of  the  pain  is  in  the 
bladder,  the  groin,  down  the  thigh,  and  in  the  testicles.  The  at- 
tack is  sometimes  preceded  by  a  chill  with  rigor,  and  accompanied 
by  retching  and  vomiting.  Sometimes  fainting  and  severe  collapse 
occur.  During  a  renal  colic  the  stone  need  not  be  passed  down  the 
ureter,  but  may  be  displaced  back  into  the  pelvis  of  the  kidney, 
only  to  be  the  cause  later  of  a  recurring  attack. 


134  DISEASES   OF   THE   KIDNEY. 

What  is  the  treatment  of  renal  calculus  ? 

If  the  disposition  to  renal  calculi  has  been  established,  the  treat- 
rtient  is  dietetic.  Digestive  articles  of  diet  taken  moderately 
should  be  advised  and  rational  measures  to  aid  assimilation  ob- 
served. It  is  not  necessary  to  abstain  from  animal  food,  but  ex- 
cess in  this  encourages  formation  of  renal  calculus. 

Medicinal  measures  consist  in  the  free  use  of  alkaline  drinks  * 
and  saline  aperients,  such  as  citrate  of  potash,  acetate  of  potash, 
the  carbonates  of  lithium  and  lime,  and  the  Epsom,  Rochelle,  and 
Grlauber's  salts.  Of  the  natural  waters,  those  of  Vichy  and  Ems 
are  recommended  as  alkaline  diluents,  and  Carlsbad,  Pullna,  and 
Friedreichshall  as  saline  aperients. 

What  are  the  surgical  procedures  resorted  to  for  calcareous  de- 
posits in  the  kidney? 

"Nephrotomy,"  "  nephro-lithotomy,"  and  "nephrectomy." 

What  is  the  treatment  of  an  attack  of  renal  colic  ? 

If  the  pains  be  unbearable,  anodynes  should  be  used  in  sufficient 
quantity  to  relieve,  in  the  form  of  hypodermics  of  morphine  or  mor- 
phine, opium  and  belladonna  suppositories.  DiiFerent  means  are 
resorted  to  to  relax  the  parts,  such  as  prolonged  immersion  of  the 
whole  body  in  hot  water  or  the  use  of  dry  cups ;  kneading  of  the 
course  of  the  ureter;  and  the  use  of  copious  draughts  of  mineral 
waters,  so  as  to  stimulate  a  further  secretion  of  urine,  which  some- 
times acts  favorably  by  causing  an  accumulation  of  urine  and  a 
pressure  upon  the  stone  from  behind. 

PYELITIS  (PYONEPHROSIS). 
What  is  pyelitis  ? 

Inflammation  of  the  pelvis  and  calyces  of  the  kidney.  It  is  most 
frequently  met  in  its  chronic  form,  and  is  susceptible  to  acute  out- 
breaks. 

What  does  obstruction  of  the  urine  lead  to  in  this  condition  ? 

Pyonephrosis,  or  a  collection  of  pus  and  blood  with  precipitated 
phosphates  and  urates  accumulated  at  the  expense  of  the  kidney 
structure  in  a  greater  or  less  amount,  occupying  the  dilated  pelvis 
and  calyces. 

What  different  courses  may  pyonephrosis  assume? 

It  may  remain  within  the  kidney  pelvis  and  steadily  enlarge,  so 
that  by  continual  dilatation  it  may  be  closely  mapped  out  externally 


PYELITIS.  135 

as  a  tumor  in  the  kidney  region.  It  may  ulcerate  through  the  pel- 
vis and  form  a  perineiohritic  abscess,  or  it  may  point  externally  and 
form  a  fistulous  tract,  which  generally  is  permanent. 

Is  pyelitis  apt  to  be  unilateral  or  bilateral? 

It  is  more  often  double,  but  if  it  depends  upon  a  cause  affecting 
one  side  only,  as  an  impacted  stone,  the  opposite  kidney  may  be 
healthy. 

What  are  the  principal  causes  which  act  to  produce  pyelitis? 

(1)  Prolonged  obstruction  to  the  passage  of  urine,  caused  by  in- 
flammation chronic  and  acute,  particularly  of  gonorrhoeal  origin, 
stricture,  and  prostatic  hypertrophy.  It  may  be  a  subacute  affec- 
tion, mild  in  character,  with  occasional  acute  outbreaks.  This  is 
most  common  with  strictures  and  prostatic  hypertrophy,  and  is 
caused  by  the  continual  damming  back  of  the  urine  upon  the  kid- 
neys, causing  a  chronic  congestion  of  the  mucous  membrane,  or  it 
may  start  as  an  acute  condition  from  an  extension  upward  of  a 
gonorrhceal  cystitis.  (2)  Renal  calculus  retained  in  the  pelvis  of 
the  kidney  or  impacted  in  the  ureter.  (3)  Tubercular  disease,  the 
deposit  of  new  growths,  and  local  irritation,  instances  of  which  are 
turpentine  and  extremely  acid  urine.  Pyelitis  also  occurs  as  a 
complication  of  various  febrile  disturbances. 

What  are  the  symptoms  of  pyelitis  ? 

Pain  in  the  back  over  the  region  of  the  kidney,  deep-seated, 
which  may  descend  down  the  course  of  the  ureter  on  either  side, 
usually  increased  on  pressure,  sometimes  dull  and  sometimes  sharp 
and  darting.  An  examination  of  the  urine  reveals  a  trace  of  albu- 
min, red  blood-corpuscles,  mucus,  and  the  characteristic  unaltered 
spindle-shaped,  irregular  epithelial  cells  which  line  the  pelvis  of 
the  kidney. 

As  the  disease  advances  these  cells  diminish  in  number  and  the 
pus-cells  increase.  In  chronic  pyelitis,  when  the  pus  in  the  urine 
becomes  very  abundant,  it  gives  it  a  turbid  appearance  when  passed, 
and  when  allowed  to  settle  precipitates  into  a  characteristic  waxy- 
looking  deposit  with  a  cupped  surface.  Chills  occur  of  variable 
duration,  accompanied  by  more  or  less  fever.  They  often  resemble 
the  various  types  of  malarial  fever.  Exercise  increases  the  pain  and 
amount  of  pus  in  the  urine.  There  is  a  frequency  of  micturition 
accompanying  pyelitis,  of  reflex  origin,  and  this  symptom  some- 
times leads   to  the  fallacy  of  mistaking  the  disease  for  bladder 


136 


DISEASES   OF   THE   KIDNEY. 


trouble.  As  the  disease  advances  the  patient  shows  its  effect  by 
general  constitutional  disturbances,  debility,  etc.  As  the  pus  accu- 
mulates the  kidney  becomes  dilated,  and  an  enlargement  may  be 


Fig.  18. 


Epithelium  from  the  Pelvis  of  the  Kidneys  (Kolliker). 

mapped  out  or  deep  fluctuation  is  distinguished.  If  ulceration 
through  the  pelvis  occurs,  perinephrtfic  abscess  sets  in.  The  exist- 
ence of  this  latter  condition,  it  should  be  remembered,  does  not 
necessarily  imply  kidney  disease ;  it  may  be  derived  from  other 
causes,  such  as  over-exertion  of  the  muscles  around  this  region, 
cold,  etc. 

What  is  the  prognosis  of  pyelitis  ? 

Such  cases  as  depend  upon  a  stricture  or  enlarged  prostate,  after  the 
relief  of  these  conditions  usually  subside  and  remain  well.  When 
dependent  upon  cancerous  or  tuberculous  deposits  the  outlook  is 
hopeless  ;  not  so,  however,  where  hydatids  or  calculi  are  the  offend- 
ing causes,  which  may  be  removed  by  surgical  interference  instead 
of  working  externally.  Pyelitis  may  consolidate  into  a  cheesy  mass 
and  give  no  further  trouble,  as  one  kidney  does  the  work.  Double 
pyelitis  is  always  serious. 

What  is  the  treatment? 

When  dependent  upon  obstructive  and  inflammatory  diseases 
lower  down  in  the  urinary  track  the  treatment  is  removal  of  cause, 
and  comprises  entirely  measures  suitable  for  these  existing  troubles. 
Occurring  during  the  course  of  febrile  disturbances,  the  principal 
malady  must  receive  increased    attention  and  nursing,  and   care 


SURGICAL   KIDNEY.  137 

should  be  taken  that  the  urine  does  not  become  too  concentrated 
and  acid.  The  general  treatment  is  antiphlogistic — cups  over  the 
kidneys,  diluent  draughts,  and  anodynes  pro  re  nata.  If  kidney- 
stone  is  suspected,  the  operation  of  nephro-lithotomy  commends  itself, 
unless  palliative  and  hygienic  measures  are  preferred.  This  is  also 
the  case  when  a  pyonephrosis  with  enlargement  of  the  kidney  exists 
to  the  extent  of  being  marked  out  externally,  when  either  the  course 
of  promoting  the  general  hygiene  of  the  patient  should  be  pursued, 
hoping  that  the  kidney  may  atrophy  and  desiccate,  or  the  operation 
of  opening  and  draining  or  removing  the  kidney  must  be  resorted 
to.  Before  proceeding  to  this  operation  the  presence  of  pus  may 
be  made  a  certainty  by  the  use  of  the  aspirator. 

SURGICAL  KIDNEY. 

What  is  this  condition? 

It  occurs  both  as  an  acute  and  a  chronic  process,  the  result  of 
disease  of  the  urethra,  prostate,  or  bladder,  or  of  instrumentation 
or  operation  upon  the  genito-urinary  tract. 

Acute  surgical  kidney  usually  appears  after  a  surgical  operation 
or  after  some  instrumental  manoeuvres,  and  is  the  result  of  a  severe 
impression  made  upon  the  sympathetic  nervous  system,  causing 
the  absorption  of  septic  material,  as  in  the  case  of  emptying  a 
paretic  bladder  which  for  many  months  and  years  has  been  accus- 
tomed to  the  presence  and  pressure  of  a  certain  amount  of  urine. 
The  unexpected  impression  may  induce  an  absorption  of  the  septic 
material  of  a  decomposing  and  putrid  urine,  or  the  sepsis  may  be 
introduced  by  the  admission  of  air  or  by  unclean  instruments 
during  an  operation.  The  pathological  condition  is  multiple  abscess- 
foci  spread  throughout  the  kidney. 

The  chronic  morbid  condition  which  may  be  included  under  the 
name  of  surgical  kidney  is  excited  by  the  various  obstructive  and 
inflammatory  conditions  of  the  bladder,  prostate,  and  urethra,  such 
as  stricture,  prostatic  hypertrophy,  chronic  cystitis,  etc.,  all  of 
which  mechanically  obstruct  the  urine  and  interfere  with  the  renal 
circulation,  producing  chronic  interstitial  nephritis,  suppurative 
nephritis,  or  pyonephritis,  propagated  by  absorption  or  through  the 
agency  of  the  nerves  or  by  an  extension  of  inflammation. 

What  are  the  symptoms? 

In  the  acute  form  they  begin  with  a  rigor  or  some  slight  chills ; 
the  temperature  rises  at  night  to  from  101°  to  103°  F.     There 


138  DISEASES   OF   THE   KIDNEY. 

may  be  a  partial  suppression  of  the  urine,  or  the  urine  may  be 
passed  in  normal  or  increased  quantities,  containing  mucus  and 
pus  in  varying  amounts,  with  hyaline  or  pus  casts.  The  patient 
suiFers  from  anorexia,  is  weak  and  depressed,  and  has  a  hot  offensive 
breath  and  a  loaded  tongue.  The  more  chronic  forms  of  sur- 
gical kidney  result  from  obstruction  to  the  flow  of  urine  of  long 
standing. 

The  symptoms  show  a  gradually  diminishing  specific  gravity  in 
the  urine,  denoting  a  deficiency  in  the  amount  of  urea  which  is 
eliminated — a  copious  admixture  of  pus  with  the  urine,  which 
when  allowed  to  stand  settles  in  the  bottom  of  a  glass  in  a  hard- 
looking,  clearly-defined  mass.  The  amount  of  albumin  in  the 
urine  is  generally  very  large — anywhere  from  1  to  3  per  cent,  by 
weight.  As  the  disease  advances  the  skin  has  a  scaly  and  muddy 
appearance.  The  intelligence  and  memory  become  affected,  and 
the  patient  toward  the  end  passes  gradually  into  a  comatose  con- 
dition. 

What  is  the  treatment? 

In  the  first  place,  preventive  treatment  is  of  most  importance,  the 
greatest  amount  of  care  being  observed  in  the  employment  of 
instruments  in  the  genito-urinary  apparatus  with  regard  to  their 
cleanliness,  etc.,  and  discretion  in  the  withdrawal  of  the  urine  from 
a  bladder  which  has  suffered  a  long  time  from  retention.  The 
cause  of  the  obstruction  to  the  urine,  if  one  exists,  should  be 
removed  if  possible,  and  in  the  case  of  prostatic  enlargement,  where 
an  operation  is  deemed  inexpedient,  a  careful  and  proper  introduc- 
tion of  the  patient  into  the  catheter  life  and  the  cleansing  of  his 
bladder  is  the  proper  course  to  pursue.  Salol  and  diuretin  have 
their  indications  and  can  be  used  to  advantage.  Such  rational 
measures  which  direct  a  proper  attendance  to  the  bowels  and  the 
observance  of  bodily  warmth  by  proper  clothing  have  their  import- 
ance and  weight. 

TUBERCULOSIS   OF  THE  KIDNEY. 

How  does  tubercle  affect  the  kidney? 

First  as  miliary  tuberculosis,  which  appears  as  minute  nodules 
scattered  throughout  the  kidney,  developing  simultaneously  here 
with  the  same  condition  in  other  organs,  and  presenting  the  appear- 
ance of  gray  granulations  in  the  tissues  between  the  uriniferous 


TUMOES    OF   THE    KIDNEY.  139 

tubes,  where  they  crowd  together.  They  appear  also  on  the  sur- 
face as  white  dots,  and  are  apt  to  be  found  at  the  same  time  in  the 
vesiculge  seminales  and  the  prostate.  Later  on,  cheesy  degenera- 
tions may  follow,  extending  from  the  papillae  through  the  sub- 
mucous tissue  of  the  pelvis ;  the  kidney  becomes  enlarged  and 
uneven  on  the  surface  by  the  infiltration  of  this  cheesy  degenera- 
tion toward  the  cortex.  Sometimes  these  cheesy  nodules  break 
down,  soften,  and  ulcerate  through  the  mucous  membrane  of  the 
pelvis,  forming  cavities  from  which  the  matter  is  discharged,  leav- 
ing the  kidneys  with  ulcerated  walls  and  a  large  part  of  the  struc- 
ture without  any  renal  tissue. 

What  are  the  symptoms  of  kidney  tuberculosis  ? 

Miliary  tubercle  produces  no  symptoms  necessarily  which  are 
referable  to  the  kidney.  When  cheesy  degeneration  occurs,  there 
may  be  at  first  no  constitutional  evidence  of  its  presence.  As  the 
disease  advances  there  is  pain  in  the  lumbar  region,  with  tenderness 
on  pressure.  The  urine  may  be  normal  or  excessive  in  quantity, 
containing  albumin,  sometimes  blood,  pus,  and  minute  cheesy 
masses,  and  broken-down  renal  tissue  later  on.  Vesical  irritation 
is  a  prominent  and  sometimes  most  distressing  symptom.  The 
disease  may  drag  along  for  many  years,  or  if  suppuration  occurs 
ursemic  symptoms  often  forewarn  a  fatal  issue. 

What  is  the  treatment? 

The  treatment  is  constitutional,  and  consists  in  the  use  of  cod- 
liver  oil,  maltine,  and  nutritious  diet.  If  the  kidney  is  broken 
down  into  an  abscess-cavity  and  a  tumor  marked  out  in  the  loin, 
an  external  incision  and  possibly  extirpation  of  the  kidney  may  be 
expedient.  It  is  important  to  discover  whether  the  disease  is 
limited  to  one  side.  Careful  examination  externally  should  assist 
in  deciding  this  question,  together  with  difi'erent  devices  which 
have  been  recommended  by  several  authorities. 

TUMORS  OF  THE  KIDNEY. 
What  benign  morbid  growths  appear  within  the  kidney  ? 

The  adenoma,  the  cavernous  angeioma,  the  rhabdo-myoma,  the. 
fibroma,  villous  papilloma,  syphilitic  gummata,  and  various   cysts. 
These  last  are   hard  to  detect  and  difficult  to  distinguish   during 
life.     The   treatment  is  ordinarily  palliative — operative  when   the 
case  requires. 


140  DISEASES   OF   THE   KIDNEY. 

CANCER  OF  THE  KIDNEY. 

Which  is  the  more  common  form  of  this  disease,  primary  or  sec- 
ondary ? 

Secondary — apt  to  be  preceded  by  disease  of  the  testicle,  liver, 
stomach,  the  breast,  or  uterus.  The  medullary  is  the  most  fre- 
quent form. 

What  are  the  symptoms  ? 

The  presence  of  a  tumor  is  almost  invariably  felt  in  the  lumbar 
region,  and  when  large  enough  to  exert  much  pressure  causes  ra- 
diating pain.  Sarcoma  and  myosarcoma  sometimes  occur  in  the 
kidney.  The  former  sometimes  attains  a  formidable  size  ;  the  lat- 
ter is  apt  to  be  congenital  in  origin. 

CYSTS  OP  THE  KIDNEY. 

Simple  cysts  occur  in  the  kidney  in  a  very  slight  degree  or  as 
complete  cystic  degeneration,  which  may  be  either  a  congenital  or 
an  acquired  condition.  The  latter  form  is  a  very  serious  aifection, 
and  is  always  fatal.  Hydatids  are  sometimes  found  in  the  kidney 
by  the  surgeon.  They  generally  occur  on  one  side,  growing  at  the 
expense  of  the  kidney  substance,  and  acquiring  a  large  size  before 
bursting,  sometimes  into  the  pelvis  of  the  kidney  or  into  the  intes- 
tines :  they  may  take  the  course  of  abscess-formation,  or  the 
echinococci  may  die  and  the  cyst  become  a  calcareous  mass. 

What  symptoms  occur  during  the  growth  of  the  cyst  ? 

None  generally  appear  until  the  cyst  is  large  enough  to  be  seen 
and  felt  in  the  kidney  region.  The  examination  of  the  urine  may 
reveal  the  presence  of  the  characteristic  vesicles  or  booklets,  and 
percussion  or  palpation  may  reveal  fremitus,  that  symptom  peculiar 
to  the  hydatid  cyst,  but  it  is  rarely  distinguished.  When  a  cyst 
becomes  ruptured  and  the  vesicles  are  discharged,  they  pass  out 
through  the  urethra  for  a  rather  long  period,  during  which  the  cyst 
is  discharging.  Sometimes  the  large  ones  cause  retention  of  urine, 
and  they  may  cause  irritation  in  the  bladder  and  cystitis.  If  no 
vesicles  are  found,  the  disease  will  be  confounded  generally  with 
.hydronephrosis. 

The  prognosis  of  this  disease  will  depend  upon  the  situation  in 
which  the  cyst  discharges  itself.  If  it  discharge  through  the  natu- 
ral outlet,  the  tendency  is  toward  recovery,  and  if  inflammation  occur 
or  if  it  discharge  elsewhere,  the  prognosis  is  rendered  more  grave. 


HYDRONEPHROSIS.  141 

What  is  the  treatment? 

There  is  no  treatment  especially  applicable  to  this  condition.  If 
the  cyst  becomes  large  enough  to  be  felt  in  the  lumbar  region  and 
does  not  burst,  the  treatment  is  operative  and  consists  of  ne- 
phrotomy. After  the  cyst  has  been  opened  the  sides  are  stitched 
to  the  external  incision. 

HYDRONEPHROSIS. 

What  does  this  condition  consist  of? 

Dilatation  by  the  accumulation  of  urine  in  the  pelvis  and  calyces 
of  the  kidney,  with  atrophy  of  the  renal  substances,  the  result  of 
a  mechanical  obstruction  to  the  urinary  outflow,  which  obstruction 
is  generally  situated  in  the  ureter.  The  distension  in  some  cases 
reaches  to  such  an  extent  that  the  irregularly  distended  kidney 
may  be  mapped  out  as  a  tumor,  which  may  be  felt  in  front  as 
high  as  the  lower  margins  of  the  ribs,  and  behind  may  be  readily 
felt  in  the  loin.  In  females  it  may  rarely  attain  such  a  size  as  to 
be  confounded  with  an  ovarian  cyst. 

What  are  the  causes? 

Mechanical  obstruction  to  the  urinary  flow,  which  obstruction 
may  be  incomplete  and  increase.  It  may  be  stricture  of  the  urethra, 
growths  of  the  bladder  or  uterus  in  the  female,  etc.  The  disten- 
sion from  these  causes  is  not  so  great  as  from  the  more  frequent 
causes  which  exist  in  the  obstruction  of  the  ureter,  calculus  im- 
paction, a  growth  in  the  bladder  which  impinges  upon  the  orifice 
of  the  ureter,  folds  in  the  mucous  membrane  of,  and  twists  in,  this 
canal. 

What  are  the  symptoms? 

No  symptoms  may  be  noticed  until  the  distension  is  sufficient  to 
be  distinguished  by  a  tumor  in  the  lumbar  region,  which  is  gener- 
ally irregular  or  lobulated,  and  may  fluctuate.  Where  the  obstruc- 
tion to  the  urinary  flow  is  incomplete,  there  may  be  a  sudden 
diminution  in  the  size  of  the  tumor,  at  which  time  there  is  a  dis- 
charge from  the  bladder  of  a  large  quantity  of  urine,  which  con- 
tains pus  and  mucus,  and  perhaps  blood.  The  symptoms  which 
accompany  it  in  the  advancement  of  its  growth  are  referable  to  the 
pressure  which  it  produces.  There  may  be  a  great  deal  of  pain, 
and  constipation  may  be  caused  by  pressure  upon  the  colon.  If 
the  cause  be  a  calculus,  the  latter  may  become  dislodged,  and  the 


142  DISEASES   OF   THE   KIDNEY. 

cyst  discharge  its  contents  and  not  refill  again.  Rupture  of  the 
sac  is  rare,  but  has  occurred,  in  which  case  the  urine  may  extrava- 
sate  into  the  peritoneal  cavity  and  septic  peritonitis  result. 

With  what  may  this  condition  be  confounded  in  diagnosis? 

Pyonephritis,  perinephritic  abscess,  and  less  commonly  with 
hydatid  cysts  and  ovarian  cysts.  Perinephritic  abscess  does  not 
produce  a  tumor  which  is  movable  and  circumscribed,  and  with  it 
there  is  apt  to  be  oedema  and  redness  of  the  skin,  which  is  rare  in 
hydronephrosis  unless  the  tumor  be  of  a  considerable  size. 

Pyonephrosis  is  only  differentiated  from  hydronephrosis  by  the 
existence  of  chills  and  rigors,  and  the  latter  may  be  transformed 
into  the  former  by  a  suppuration  taking  place  in  the  sac. 

Ovarian  cysts  may  be  excluded  by  the  relation  of  the  colon  to 
the  growth,  it  being  behind  an  ovarian,  but  in  front  of  a  renal, 
tumor.  The  examination  by  the  rectum  and  vagina  will  also  aid 
in  excluding  an  ovarian  tumor.  This  sign  is  not  invariable,  as 
when  a  renal  tumor  acquires  a  large  size  the  colon  may  get  behind, 
and  rarely  an  intestinal  fold  has  been  found  in  front  of,  an  ovarian 
cyst. 

What  is  the  treatment? 

If  the  cause  be  decided  upon,  and  it  is  found  to  be  a  temporary 
obstruction,  aspiration  should  be  resorted  to.  If  ct  twist  in  the 
ureter  is  the  cause,  kneading  the  abdomen  may  be  successful  in 
undoing  it.  Care  should  be  taken,  however,  not  to  rupture  the 
tumor  by  unduly  severe  manipulation.  If,  on  the  other  hand,  the 
obstruction  appears  permanent,  nephrotomy  should  be  employed 
and  continual  drainage  kept  up,  unless  the  obstruction  can  be 
removed,  or  if  it  spontaneously  disappears  later  on,  the  remaining 
fistulas  may  be  allowed  to  close. 

SYPHILIS  OF  THE  KIDNEY. 

How  does  it  show  itself? 

As  amyloid  degeneration,  interstitial  chronic  inflammation,  cir- 
cumscribed cirrhosis,  sometimes  fatty  degeneration,  also  as  circum- 
scribed, gummatous  nodules  alone  or  combined  with  any  of  the 
above  appearances.  The  vessels  of  the  kidney  may  also  be  affected 
by  syphilitic  atheroma.  The  albuminuria  which  sometimes  appears 
in  the  early  stages  of  syphilis  is  thought  by  some  to  be  due  to 
mercury,  but  appears  in  cases  where  this  remedy  has  not  been 


NEPHRORRAPHY,  NEPHROTOMY,  AND  NEPHRECTOMY.    143 

used.  The  iodides  may  certainly  be  the  sole  cause  of  albumin 
in  the  urine.  The  treatment  of  syphilis  of  the  kidney  is  con- 
stitutional. 

NEPHRORRAPHY  AND  NEPHROTOMY. 

What  are  the  various  operations  which  the  surgeon  is  called  upon 
to  perform  for  the  surgical  relief  of  kidney  affections  ? 

Nephrorraphy,  nephrotomy,  nephro-lithotomy,  and  nephrectomy. 

In  nej)hrorra])hy  the  incision  is  made  parallel  to  the  last  rib, 
about  1  inch  below  it  and  4  inches  in  length,  reaching  down  to  the 
kidney  fat.  The  fatty  tissues  are  torn  asunder  for  the  purpose  of 
reaching  the  fibrous  capsule,  which  is  opened  and  sewed  to  the 
edges  of  the  wound  by  sutures  of  catgut. 

In  nephrotomy  an  incision  is  made  similar  to  that  for  lumbar 
colotomy,  and  is  oblique  from  behind  forward,  from  3  to  4  inches 
long,  commencing  at  the  outer  edge  of  the  erector  spinas  muscle. 
The  first  cut  is  a  deep  free-hand  incision,  dividing  the  deep  fascia 
and  muscular  tissues,  when  it  will  reveal  the  quadratus  lumborum 
muscle,  which  also  should  be  divided  if  in  the  way.  The  deep 
lumbar  tissue  being  now  reached,  an  opening  through  this  will 
reveal  the  kidney  fat,  which  is  torn  through  and  separated  in  order 
to  discover  a  cyst,  abscess,  etc.  If  such  be  the  case,  an  incision  is 
made  and  drainage  efi'ected  by  sewing  the  walls  of  the  sac  to  the 
sides  of  the  wound,  and  drainage-tubes  are  introduced. 

Nephro-lithotomy  is  simply  the  above  operation  for  the  removal 
of  renal  calculus,  which  should  always  be  searched  for  by  the  intro- 
duction of  the  finger  to  the  pelvis,  as  it  often  enters  into  the 
causation  of  many  of  the  surgical  afiections  of  the  kidney. 

NEPHRECTOMY. 

What  does  this  operation  consist  of? 

Extirpation  of  the  kidney. 

How  many  kinds  of  nephrectomy  are  there  ? 

Two — lumbar  and  abdominal.  The  latter  procedure  was  formerly 
looked  upon  as  being  full  of  danger,  it  being  necessary  to  open  the 
peritoneal  cavity,  and  the  former  was  preferred  for  the  absence  of 
this  objection  and  on  account  of  the  easy  manner  in  which  the 
wound  could  be  drained  in  the  recumbent  position.  At  the  pres- 
ent day,  when  antiseptic  surgery  is  attended  with  such  marked 
success,  there  are  many  who  favor  the  abdominal  section  under  its 


144  ABNORMALITIES   OF   THE   URINE. 

precautions,  on  account  of  the  ease  with  which  the  kidney  may  be 
extirpated  through  an  anterior  wound,  and  the  facility  which  both 
organs  can  be  manipulated  and  examined  by  this  procedure.  There 
is  no  doubt  about  the  advisability  of  the  lumbar  operation  where  it 
is  not  certain  that  extirpation  of  the  kidney  will  be  necessary,  slight 
disease  or  involvement  only  being  expected,  and  for  nephro-lithot- 
omy  and  where  exploration  is  called  for,  on  account  of  rupture  or 
severe  wounds  which  have  resisted  ordinary  measures  and  drainage. 

Lumbar  Nephrectomy. — An  incision  about  4  inches  long  is  made 
in  an  oblique  direction  downward  and  forward  between  the  ribs  and 
the  crest  of  the  ilium,  within  about  an  inch  from  the  twelfth  rib, 
freely  down  to  the  fatty  covering  of  the  kidney,  through  which 
the  fibrous  capsule  is  reached.  The  organ  may  be  readily  sep- 
arated from  the  surrounding  structures  without  opening  the  capsule, 
unless  inflammatory  adhesions  exist.  If  this  operation  is  done,  as 
is  sometimes  the  case,  after  a  previous  nephrotomy,  it  will  be 
necessary  to  remove  the  kidney  out  of  its  adherent  capsule.  If 
there  is  not  enough  room  with  the  first  incision,  a  cross  cut  may  be 
made  for  this  purpose.  The  vessels  of  the  kidney  are  ligated  by 
a  heavy  silk  ligature  in  one  loop,  the  ureter  being  also  secured 
by  the  same  means.  After  the  kidney  is  drawn  out  through  the 
wound,  a  second  ligature  is  passed  around  the  entire  pedicle,  and 
between  this  and  the  other  two  the  kidney  is  severed  from  its  attach- 
ments. All  bleeding  points  should  be  carefully  stopped  by  the  use 
of  the  clamp  and  ligature.  The  wound  is  then  drained  by  a  drain- 
age-tube, and  the  opening  closed  by  interrupted  sutures  and  dressed 
antiseptically.  It  is  generally  necessary  to  leave  the  drainage-tube 
in  for  five  or  six  days,  making  it  shorter  at  each  dressing. 

In  ahdominal  nephrectomy  the  kidney  is  reached  by  an  abdomi- 
nal incision,  which  is  generally  made  along  the  outer  border  of  the 
rectus  muscle. 

ABNORMALITIES  OF  THE  URINE. 

What  are  the  different  affections  to  which  are  referable  an  excess 
of  the  normal  or  the  presence  of  abnormal  constituents  in 
the  urine  ? 

Oxaluria,  phosphaturia,  and  the  uric-acid  diathesis. 

How  does  oxaluria  show  itself  in  the  urine  ? 

By  the  presence  of  octahedral  crystals  of  oxalate  of  lime  and 
the  dumb-bell-shaped  crystals. 


PHOSPHATUEIA.  ]  45 

What  does  their  presence  indicate? 

They  generally  appear  in  nervous  subjects,  and  accompany  dis- 
ordered digestion,  impaired  or  ungratified  sexual  appetite,  excessive 
venery,  or  any  continuous  mental  strain.  They  are  sometimes  acci- 
dental, the  result  of  the  abundant  use  of  rhubarb  and  tomatoes  as 
food.  Such  patients  as  suJffer  from  vspermatorrhoea  and  find  it  out, 
or  those  who  read  quack  pamphlets  and  are  led  to  believe  that  they 
are  suffering  from  sexual  ailments,  are  favorable  subjects  for  the 
development  of  this  malady. 

What  is  the  treatment? 

The  mineral  acids,  sulphate  of  strychnine,  etc.  may  be  given  by 
way  of  tonics  and  for  the  improvement  of  the  digestion.  The  real 
treatment  is  hygienic,  and  consists  in  regulating  the  functions, 
out-door  exercise,  etc.,  with  an  endeavor  to  counteract  the  neurotic 
element. 

What  is  the  condition  in  phosphaturia  ? 

The  urine  is  unnaturally  alkaline  or  neutral,  pale  in  color,  of  light 
specific  gravity,  and  of  copious  flow;  it  has  a  tendency  to  decom- 
pose rapidly  on  standing.  Phosphatic  urine  deposits  the  excess  of 
phosphate,  which  occasions  a  great  deal  of  worry  in  one  who  is  con- 
tinually investigating  the  character  of  his  urine,  it  being  taken  for 
seminal  fluid,  in  which  belief  he  is  encouraged  by  the  unscrupulous. 

Upon  what  does  phosphatic  urine  depend? 

It  is  generally  referable  to  a  nervous  tendency  or  some  excess  or 
overstrain,  which  reacts  upon  a  nervous  system,  such  as  the  undue 
use  of  tobacco,  excessive  venery,  and  various  mental  strains.  It  is 
often  associated  with  impaired  digestive  function,  and  is  mostly  con- 
fined to  youth. 

What  are  the  symptoms? 

The  symptoms  which  accompany  this  condition  are  those  of  gen- 
eral malaise,  lack  of  energy,  imperfect  digestion,  despondency,  etc. 

What  is  the  treatment? 

To  remove,  if  possiVjle,  the  cause,  establish  a  habit  of  regular 
living,  whip  up  the  energy,  and  improve  the  general  morale.  As 
the  malady  is  one  which  is  dependent  upon  the  sympathetic  nerv- 
ous system,  measures  which  are  directed  toward  this  system  for 
relief  are  most  liable  to  attain  success.  Change  of  air  and  of  sur- 
roundings, and  stimulating  an  active  interest  in  some  direction, 
10— G-U. 


146  DISEASES   OF   THE   TESTICLE. 

would  appear  to  be  a  rational  means  to  pursue.     The  mineral  acids 
and  bitter  tonics  are  quite  applicable  by  way  of  medication. 

What  are  the  causes  of  over-acidity  of  the  urine  ? 

Rheumatic  or  uric-acid  diathesis.  The  free  use  of  wines  and 
liquors,  especially  the  malt  liquors  and  the  sweet  wines,  which 
tend  to  produce  the  uric-acid  crystals,  are  the  source  of  irritation 
during  the  passage  of  the  urine. 

What  are  the  effects  on  the  urinary  tract  caused  by  over-acidity 
of  the  urine  ? 
It  may  produce  irritation  of  the  neck  of  the  bladder,  or  ure- 
thritis. It  may  deposit,  and  under  certain  conditions  produce,  a 
uric-acid  calculus  somewhere  in  the  urinary  tract,  or  it  may  be  the 
sole  cause  of  nephralgia. 

What  is  the  treatment? 

The  treattnent  consists  in  properly  regulating  the  diet  to  counter- 
act the  acid  secretion  of  the  urine,  which  may  be  favored,  by  the 
use  of  a  light  animal  diet,  the  free  use  of  the  mild  spring  waters, 
such  as  Poland,  etc.,  to  filter  through  the  kidneys,  but  not  the 
alkaline  waters,  which  do  not  tend  to  better  this  condition  ;  out-door 
exercise  and  regularity  of  living,  and  perhaps  the  employment  of 
a  mineral  acid. 

DISEASES  OF  THE  TESTICLE. 

What  is  the  general  anatomy  of  the  testicles  ? 

Each  one  is  suspended  within  the  scrotum  by  the  spermatic  cord 
on  either  side.  The  left  testicle  hangs  slightly  lower  than  the 
right.  Both  are  surrounded  and  enveloped  by  certain  coverings, 
which  enclose  each  one  separately  in  its  own  envelope.  The  most 
adjacent  coverings  are  the  tunica  vaginalis  and  albuginea.  The 
tunica  vaginalis  is  a  serous  sac  which  invests  the  whole  testicle  ex- 
cept at  the  attachment  of  the  epididymis.  It  covers  the  epididymis 
externally,  and  is  reflected  for  a  short  distance  up  the  cord.  This 
sac,  which  was  originally  derived  from  the  peritoneum  at  the  time 
of  the  descent  of  the  testicle,  although  it  ordinarily  after  birth 
severs  its  connection  with  the  peritoneal  cavity  and  is  entirely  cut 
off  from  it,  sometimes  has  the  opening  remaining  pervious,  and  thus 
leads  to  congenital  hernia. 

The  tunica  albuginea  constitutes  a  fibrous  investment  for  the 


ANOMALIES.  147 

testicle,  and  from  it  fibrous  prolongations  or  trabeculge  extend 
into  the  substance  of  the  organ  to  form  compartments  for  the 
reception  of  the  coils  of  the  seminiferous  tubes.  These  tubes, 
which  constitute  the  glandular  construction  of  the  testicle,  are 
formed  into  cones  and  divided  by  the  fibrous  partitions  of  the  tunica 
albuginea.  These  seminiferous  tubes  anastomose  freely,  and  are 
lined  by  cells  which  are  active  in  the  formation  of  the  spermatozoa. 
The  epididymis  is  situated  on  the  posterior  and  upper  portion 
of  the  testicle,  and  is  partly  composed  of  convoluted  ducts,  which 
combine  in  their  efferent  course  from  the  tubes  to  form  this  body. 
The  upper  part  of  the  epididymis  is  called  the  globus  major,  and 
in  the  central  portion  is  the  canal  into  which  all  the  ducts  empty. 
This  canal  is  convoluted  to  a  greater  extent  at  the  lower  end,  where 
it  forms  the  globus  minor  or  tail  of  the  epididymis.  Here  the  ex- 
cretory duct  of  the  testicle  commences — namely,  the  vas  deferens, 
which  contributes  to  the  formation  of  the  spermatic  cord,  passes 
through  the  inguinal  canal,  over  the  pubic  bone,  into  the  pelvis  to 
the  base  of  the  bladder,  where  it  joins  with  the  duct  of  the  semi- 
nal vesicle,  forming  the  ejaculatory  duct,  and  opens  in  the  prostatic 
sinus. 

What  are  the  anomalies  affecting  the  testicles? 

Absence  of  one  or  both  testicles. 

Where  is  the  testicle  formed  in  the  embryo  ? 

In  the  abdominal  cavity,  behind  the  peritoneum  ;  at  the  end  of 
the  ninth  month  of  foetal  life  it  has  usually  passed  into  the  scrotum. 
When,  however,  the  scrotum  is  empty  on  one  or  both  sides,  the 
testicle  should  be  searched  for  in  the  inguinal  canal,  through  which 
it  descends  before  birth,  or  at  some  point  out  of  its  normal  course, 
where  it  has  been  arrested.  The  testicle,  although  it  descends 
normally,  sometimes  during  the  first  week  after  birth,  may  be 
retained  for  variable  periods  and  descend  anywhere  from  birth  to 
the  age  of  puberty,  and  even  later  periods  have  been  known.  An 
individual  with  both  testicles  retained  may  enjoy  the  full  vigor  of 
his  sexual  capacity  and  yet  be  sterile.  In  regard  to  this,  however, 
a  microscopic  examination  must  decide  any  question.  The  testicle 
retained  in  an  abnormal  position  is  liable  to  cause  pain,  either  as  a 
result  of  disease  from  gonorrhosal  inflammation,  etc.,  or  as  a  simple 
result  of  pressure. 


148  DISEASES   OF   THE   TESTICLE. 

What  is  the  treatment  of  retained  testicle  ? 

Operations  are  resorted  to  for  the  relief  of  this  condition,  and 
may  meet  with  success.  Sometimes  the  testicle  can  be  manipulated 
outside  of  the  external  ring  in  early  life,  and  by  being  retained 
here  allowed  to  develop  in  the  ordinary  manner.  Although  the 
testicle  is  more  exposed  in  this  position,  the  chances  of  a  hernia 
developing  and  becoming  strangulated  are  lessened.  If  the  testicle 
is  in  the  inguinal  canal,  and  cannot  be  manipulated  out  of  the  ring, 
it  must  either  be  left  alone  in  its  first  position  or  an  operation  per- 
formed for  its  relief  and  an  attempt  made  to  place  it  in  the  scrotum. 
If  the  cord  be  too  short  to  allow  this  measure,  castration  may  be 
resorted  to. 

Is  the  testicle  sometimes  displaced  during  life  ? 

The  testicle  is  sometimes  dislocated,  either  by  sudden  muscular 
action,  when  it  has  been  drawn  up  into  the  inguinal  canal,  or  by 
traumatism. 

What  may  cause  atrophy  of  the  testicle  ? 

Atrophy  may  come  on  after  an  inflammation.  Orchitis,  when  it 
complicates  mumps  or  anything,  such  as  a  morbid  growth,  which 
acts  to  interfere  with  the  vascular  supply  of  the  organ,  may  cause 
this  condition. 

HEMATOCELE. 
What  is  hsematocele? 

An  effusion  of  blood  into  the  sheath  of  the  testicle  (the 
tunica  vaginalis)  or  into  a  hydrocele,  a  pre-existing  cyst  of  the 
testicle  or  of  the  cord.  It  is  of  traumatic  origin.  It  either  comes 
on  after  an  injury  to  the  scrotum,  which  suddenly  swells  and 
becomes  darkly  discolored,  or,  in  the  case  where  hydrocele  has 
already  existed,  as  a  result  of  some  violence  or  operative  procedure, 
when  the  sac  becomes  swollen  and  painful. 

What  is  the  treatment  ? 

Rest  in  a  recumbent  position,  support  to  the  testicle,  with  cold 
lotions,  and  after  the  acute  symptoms  have  subsided  the  patient 
may  be  allowed  to  go  around  with  proper  support  and  a  certain 
amount  of  pressure  applied  to  the  affected  portion  for  a  time,  during 
which  the  blood  becomes  gradually  absorbed.  Suppuration  may 
take  place,  in  which  case  a  free  incision  becomes  necessary,  and 
proper  drainage  should  be  established. 


HYDEOCELE.  149 

HYDROCELE. 
What  is  hydrocele? 

Hydrocele  is  an  accumulation  of  serous  fluid  within  the  sac  of 
the  tunica  vaginalis.  It  may  be  an  acute  or  a  chronic  condition, 
congenital  or  acquired.  Encysted  hydrocele  is  a  cyst  connected 
with  the  testicle  or  cord.  The  ordinary  form  of  hydrocele  is  the 
collection  of  fluid  in  the  tunica  vaginalis  and  connected  with  the 
testicle.  This  condition  may  coexist  with  an  encysted  hydrocele, 
which  may  be  of  the  testicle  proper,  the  epididymis,  the  spermatic 
cord,  or  may  complicate  a  congenital  hernia,  then  often  called 
congenital  hydrocele. 

What  is  acute  hydrocele? 

It  is  simply  an  inflammatory  efi'usion  of  fluid  coming  on  with 
inflammation  of  the  testicle.  It  is  usually  reabsorbed  without 
treatment.  It  occurs  sometimes  after  the  evacuation  of  a  chronic 
hydrocele,  which  is  treated  by  stimulating  injections. 

What  is  chronic  hydrocele? 

Here  the  effusion  takes  place  slowly,  causing  a  gradual  swelling, 
the  appearance  of  which  is  generally  the  first  thing  which  calls  its 
attention  to  the  patient,  as  there  is  apt  to  be  no  pain  connected  with 
it.  The  amount  of  fluid  tends  to  increase  indefinitely,  causing  the 
growth  in  some  cases  to  reach  a  very  extensive  size. 

What  are  the  symptoms  of  hydrocele  ? 

The  existence  of  an  irregular  swelling  in  the  scrotum,  larger 
below  than  above,  having  generally  a  more  or  less  translucent 
appearance,  and  which  cannot  be  reduced  by  pressure  toward  the 
inguinal  region.  It  fluctuates  and  is  tense.  Percussion  of  the 
mass  gives  a  flat  note.  By  holding  the  tumor  between  the  eye  and 
a  light  when  it  is  made  very  tense,  the  translucency  will  becomci 
very  apparent,  and  the  diagnosis  between  this  and  a  hernia  be 
readily  established.  The  latter  condition  is  generally  largest  above, 
and  commences  from  the  external  ring  and  grows  downward,  is 
doughy  in  feeling,  and  percussion  over  the  gut  will  render  a  tym- 
panitic note.  If  the  diagnosis  cannot  be  established  otherwise,  an 
exploratory  puncture  must  be  made.  This  symptom  of  translu- 
cency is  sometimes  clouded  in  cases  of  old  hydrocele,  where  the  sac 
has  become  thickened  and  fibrous  by  continued  distension,  or  when 
the  fluid  contents  is  not  transparent  on  account  of  the  admixture 
of  blood  or  pus. 


150  DISEASES   OF   THE   TESTICLE. 

What  are  the  causes  of  hydrocele  ? 

Anything  which  continually  interferes  with  the  proper  circula- 
tion of  the  blood  in  the  testicle  may  act  as  a  cause  for  hydrocele ; 
injuries  and  strains  may  induce  its  formation. 

What  is  the  general  nature  of  the  fluid  contained  in  hydrocele? 

It  is  generally  serous  and  of  a  yellow  color.  It  may  be  blood- 
stained as  the  result  of  an  injury  or  inflammation,  it  may  be  sero- 
purulent  in  broken-down  subjects,  or  suppuration  may  take  place. 

What  is  the  treatment  of  hydrocele  ? 

The  treatment  aims  at  radical  or  only  temporary  relief  of  this 
condition.  The  latter  is  obtained  by  a  simple  puncture  of  the 
hydrocele  sac  and  withdrawal  of  the  fluid,  which  procedure  has 
to  be  repeated  at  each  subsequent  refilling  of  the  sac. 

How  is  the  tapping  operation  effected  ? 

While  the  patient  is  in  an  upright  position  the  hydrocele  is  manip- 
ulated and  the  position  of  the  testicle  ascertained.  It  is  usually 
situated  behind  and  somewhat  below  the  centre,  although  it  is 
sometimes  found  in  front.  The  swelling  is  then  grasped  and  made 
tense  by  encircling  the  scrotum  firmly  above  it.  An  oiled  canula 
and  trocar  is  then  introduced  at  about  the  centre  of  the  hydrocele 
obliquely  upward  and  with  a  rapid  puncture.  The  trocar  being 
withdrawn,  the  canula  is  introduced  up  to  the  hilt.  Tapping  may 
be  also  done  by  the  use  of  an  aspirator  and  needle.  This  procedure 
is  generally  a  simple  one,  and  accompanied  by  no  other  untoward 
symptoms  than  that  the  patient  may  occasionally  feel  somewhat 
faint  during  the  operation. 

,How  is  the  radical  cure  of  hydrocele  effected  ? 

The  tapping  operation  sometimes  is  radical,  and  there  is  no 
return  of  fluid.  This  is  probably  caused  by  a  certain  amount 
of  absorptive  inflammation  which  produces  a  closure  of  the  sac. 
The  same  result  was  formerly  aimed  at  by  the  introduction  after 
tapping  of  a  tent  or  seton.  In  children  a  radical  cure  may  some- 
times be  effected  by  external  irritation,  by  means  of  manipulation, 
or  by  stimulating  applications,  but  in  the  adult  the  means  most 
abundantly  practised  at  the  present  day  for  the  radical  cure  consist 
either  in  the  injection  of  the  sac  or  in  its  entire  excision  by  a  cut- 
ting operation. 


HYDEOCELE.  151 

In  what  cases  of  hydrocele  is  the  injection  treatment  applicable  ? 

In  all  cases  except  where  the  walls  of  the  sac  are  intensely  thick- 
ened and  where  its  contents  are  bloody  or  sero-purulent. 

What  substances  are  employed  for  this  injection  treatment? 

Iodine,  carbolic  acid,  solutions  of  alum  or  of  sulphate  of  zinc, 
and  chloride  of  zinc.  The  best  method  is  the  use  of  carbolic  acid. 
It  is  best  always  to  endeavor  to  produce  a  cure  by  tapping-  alone 
first,  before  resorting  to  injection.  If  the  tumor  be  extremely 
large,  it  is  well  to  reduce  its  size  by  one  or  two  tappings  before 
the  injection  ;  also,  if  there  be  blood  in  the  fluid  removed,  it  is  well 
to  delay  the  injection  until  a  future  tapping  reveals  clear  fluid.  In 
adopting  the  injection  method  for  the  cure  of  hydrocele  the  follow- 
ing course  is  pursued  :  The  needle  of  a  syringe  containing  the  fluid 
to  be  injected  is  detached  and  introduced  into  the  hydrocele.  Then 
the  aspirating  needle  is  introduced  and  the  contents  of  the  hydro- 
cele drawn  off"  to  the  last  drop,  after  which  the  aspirator  is  with- 
drawn, and  the  injection  fluid  is  introduced  through  the  first 
needle,  the  point  of  which  you  are  certain  is  in  the  sac,  as  it  has 
been  introduced  before  the  hydrocele  was  emptied.  The  tincture 
of  iodine  is  introduced,  1  to  3  parts  of  water  to  a  drachm  or  two 
drachms.     The  following  prescription  has  been  recommended : 

B.  lodi.,  3ij  ; 

Potas.  iod.,  3SS ; 

Sps.  vini  rect.,         ^ss. — M. 

A  drachm  or  two  of  this  is  used  at  a  time.  The  injection  of  car- 
bolic acid  has  advantages  over  all  other  methods,  in  that  it  is  more 
speedy,  causes  less  pain,  and  is  accompanied  with  less  danger,  and 
is  therefore  to  be  recommended  before  any  other  method  for  the 
radical  treatment  o:^  this  condition.  The  steps  in  the  operation  are 
as  have  already  been  described,  and  after  the  fluid  is  withdrawn  from 
40  minims  to  j  drachm  of  pure  deliquesced  carbolic  acid,  according 
to  the  size  of  the  hydrocele,  is  injected,  following  which  the  needle  is 
withdrawn  and  the  sac  gently  manipulated  to  ensure  contact  of  the 
acid  with  the  entire  surface  of  the  serous  membrane.  The  radical  cure 
of  hydrocele  by  incision  under  antiseptic  precautions  becomes  neces-. 
sary  where  the  sac  is  unduly  thickened  and  where  the  contents 
remain  continuously  bloody  or  sero-purulent,  or  in  cases  where  the 
injection  operation  fails.  It  is  a  more  formidable  operation  ;  may 
be  accompanied  by  a  great  deal  of  shock  and  loss  of  blood,  and  is 


152  DISEASES   OF   THE   TESTICLE. 

therefore  not  to  be  resorted  to  except  under  the  above  circumstances 
or  unless  the  injection  method  have  failed.  The  operation  must 
be  done  under  the  most  rigid  antisepsis.  An  incision  about  2  inches 
long  is  made  through  the  diiferent  layers  of  the  scrotum  down  to 
the  tunica  vaginalis,  before  opening  which  all  bleeding  points  are 
stopped.  The  incision  is  then  continued,  throughout  its  whole 
length,  through  the  walls  of  the  sac,  which,  if  found  very  thick, 
should  be  removed ;  otherwise  the  serous  membrane  is  sewed  by 
numerous  stitches  all  around  to  the  edges  of  the  wound,  which  is 
then  sutured,  drained,  and  dressed  antiseptically. 

What  is  the  cause  of  congenital  hydrocele  ? 

It  results  from  the  existence  of  an  open  canal  between  the  peri- 
toneum and  the  tunica  vaginalis  ;  this  canal  normally  becomes  oblit- 
erated after  the  descent  of  the  testicle,  forming  a  fibrous  cord. 

How  is  it  distinguished  ? 

We  have  a  tumor  in  the  scrotum,  which  appears  soon  after  birth, 
runs  up  into  the  inguinal  canal,  gives  an  impulse  on  coughing,  flat- 
ness on  percussion,  is  reducible,  feels  soft,  and  is  translucent.  It 
must  be  differentiated  from  a  hernia,  which  need  not  appear  soon 
after  birth,  but  comes  at  any  time,  gives  a  resonant  note  on  per- 
cussion, and  when  reduced  returns  to  the  peritoneal  cavity  suddenly, 
and  generally  with  a  gurgling  sound ;  it  has  a  doughy  feel  and  is 
never  translucent.  Hydrocele  may,  however,  be  complicated  by  a 
hernia. 

What  is  the  treatment  ? 

Congenital  hydrocele  should  never  be  injected.  The  aim  should 
be  to  obliterate  the  neck  of  the  sac  by  the  application  of  a  well- 
fitting  truss.  After  this  has  been  accomplished  the  fluid  will  gene- 
rally become  absorbed  after  a  couple  of  months.  If  this  fails  to 
take  place,  it  may  be  treated  as  a  simple  hydrocele  by  injection  or 
incision. 

Is  congenital  hydrocele  found  in  adults? 

Only  rarely.  An  old  hernial  sac,  the  neck  of  which  has  become 
obliterated  by  the  wearing  of  a  truss  or  by  being  plugged  by 
omental  tissue,  may  fill  with  fluid,  and  thus  form  a  hydrocele  of 
the  hernial  sac.  The  existence  of  this  condition  can  be  established 
by  history  alone.  It  should  be  treated  operatively  in  the  manner 
adopted  for  the  radical  cure  of  hernia. 


HYDROCELE   OF   THE   SPERMATIC   CORD.  153 

SPERMATOCELE. 

What  is  spermatocele? 

An  accumulation  of  fluid  containing  spermatic  elements  in  the 
tunica  vaginalis,  or  it  is  a  cyst  situated  within  or  arising  from  the 
testicle.  It  is  apt  to  coexist  with  hydrocele,  and  the  existence 
of  spermatic  elements  in  the  hydrocele  fluid  is  explained  as  having 
resulted  from  puncture  of  a  spermatocele  which  impinges  so  much 
upon  the  hydrocele  as  to  become  obscured  by  it,  or  from  rupture  into 
the  tunica  vaginalis  early  in  its  growth,  having  pre-existed  as  a  cyst. 

What  are  the  symptoms  of  spermatocele  ? 

When  coexisting  with  hydrocele  and  jutting  into  the  sac  of  the 
latter  there  are  no  symptoms  which  distinguish  it.  When  it  exists 
alone,  there  is  a  sensation  of  uneasiness  akin  to  pain  experienced 
at  the  head  of  the  epididymis,  which  often  passes  unnoticed  by 
many  until  a  little  tumor  is  found  by  the  patient  by  accident 
This  tumor,  when  discovered  early,  seems  to  be  nothing  but  a 
thickening  around  the  region  of  the  top  of  the  testicle,  but  goes  on 
increasing,  sometimes  so  slowly  that  its  growth  is  not  noticed  by 
the  patient.  It  continues,  however,  to  increase  indefinitely.  As  it 
increases  the  walls  are  tense  and  fluctuation  is  made  out  with 
difficulty.  Its  position  at  the  top  of  the  testicle  is  kept,  and  it 
tends  to  become  heart-shaped,  with  the  notch  above.  It  is  generally 
translucent,  but  the  fluid  may  be  somewhat  milky  or  dark-colored, 
which  is  discovered  upon  tapping,  while  the  microscope  reveals 
the  presence  of  the  spermatic  elements,  some  lively  and  vibratile, 
while  others  are  more  or  less  decomposed.  By  their  presence  alone 
the  diagnosis  can  be  positively  established.  The  patient  is  apt  to 
be  hypochondriacal  and  have  various  notions  as  to  loss  of  sexual 
power  and  animal  vigor. 

What  is  the  treatment? 

The  treatment  should  always  be  by  injection  or  incision,  as  after 
tapping  a  spermatocele  will  invariably  refill. 

HYDROCELE  OF  THE  SPERMATIC  CORD. 

In  what  different  forms  does  hydrocele  of  the  spermatic  cord 
appear  ? 

Either  difi'use  or  encysted.  When  difi"use  the  loose  connective 
tissue  surrounding  it  becomes  infiltrated,  resembling  an  oedema.  It 
is  a  rare  condition. 


154  DISEASES  OF  THE   TESTICLE. 

What  are  the  symptoms  ? 

The  existence  of  a  tumor  of  a  cylindrical  shape  in  the  inguinal 
region  which  does  not  extend  down  into  the  tunica  vaginalis  proper. 
It  is  apt  to  be  confounded  with  an  omental  hernia  in  this  situation, 
but  the  latter  condition  gives  an  impulse  on  coughing,  and  when 
reduced  in  the  recumbent  position  will  remain  up,  while  the  diffuse 
hydrocele,  although  very  often  appareutli/  rediicihle,  rapidly  returns 
when  left  alone.  If  the  hernia  be  irreducible  the  diagnosis  is  more 
difficult. 

What  is  the  treatment  of  diffuse  hydrocele? 

Small  punctures  may  be  made  at  the  lower  portion  of  the  swell- 
ing and  repeated  at  short  intervals.  Large  incisions  are  more 
serious,  only  called  for  as  an  exploratory  procedure  when  the  dia- 
gnosis is  uncertain. 

What  is  an  encysted  hydrocele  of  the  cord? 

Cysts  are  formed  at  different  points  along  the  remains  of  the 
peritoneal  process,  which  has  not  become  completely  occluded ;  or 
cysts  develop  in  the  connective  tissue  surrounding  the  cord.  There 
may  be  one  large  cyst  or  several  small  ones  strung  together. 

The  treatment  for  a  large  encysted  hydrocele  is  injection,  whereas 
for  a  number  of  small  ones  which  connect  an  incision  is  necessary. 

ORCHITIS. 
What  is  inflammation  of  the  testicle  proper  called? 

Orchitis. 

Does  it  occur  as  a  distinct  affection  and  unassociated  with  inflam- 
mation of  the  epididymis  ? 

Inflammation  of  the  body  of  the  testicle,  its  secreting  structure, 
is  generally  unattended,  when  it  occurs  primarily,  with  epididymitis, 
but  this  latter  affection  may  secondarily  be  accompanied  by  an 
extension  of  the  inflammation  to  the  body  of  the  testicle,  or  if  the 
cause  be  an  injury  they  may  both  be  affected  simultaneously. 

What  are  the  causes  of  inflammation  of  the  secreting  structure  of 
the  testicle,  or  true  orchitis  ? 

This  affection  is  uncommon.  It  complicates  mumps  ("  meta- 
static orchitis"),  when  it  generally  comes  on  at  about  the  end  of 
the  first  week,  usually  affecting  only  one  testicle..  Orchitis  as  a 
result  of  injury  tends  to  suppurate  and  result  in  gangrene  or  be 


OECHITIS.  155 

followed  by  atrophy  of  the  organ.  The  mild  and  subacute  form 
of  this  malady  comes  on  sometimes  in  those  suffering  from  chronic 
urethral  and  prostatic  diseases,  and  it  occurs  occasionally  spontane- 
ously without  any  assignable  cause. 

What  are  the  symptoms? 

In  severer  cases  it  is  often  preceded  by  slight  chills  and  fever, 
anorexia,  etc.  There  is  a  gradual  enlargement  in  the  testicle, 
accompanied  by  a  great  deal  of  pain,  according  to  the  extent  of  the 
swelling.  It  is  very  sensitive  to  pressure.  The  pain  continues  for 
several  days,  when  it  either  commences  to  slightly  decline  or 
entirely  ceases,  which  latter  condition  points  toward  gangrene. 
The  shape  of 'the  testicle  is  ovoid,  and  the  testicle  itself  is  hard 
and  indurated  ;  the  epididymis  cannot  be  made  out,  and  the  scrotum 
is  often  red  and  oedematous.  When  suppuration  intervenes  it  is 
generally  preceded  by  a  chill,  after  which  the  enlargement  rapidly 
increases  and  becomes  soft. 

The  suppuration  points  toward  the  surface,  and  if  the  pus  be 
allowed  to  escape  atrophy  of  the  remaining  structure  takes  place, 
or  perhaps  suppuration  in  another  portion.  Sometimes  a  fistula 
remains,  which  may  be  surrounded  by  sprouting  granulations,  pre- 
venting proper  drainage  of  the  pus-cavity,  causing  either  softening 
and  pus-formation  or  leading  to  general  decline  of  health.  If  the 
abscess-formation  of  an  orchitis  does  not  come  to  the  surface,  the 
symptoms  may  continue  for  a  long  period,  while  the  softening 
gradually  becomes  contracted  to  an  indurated  mass  and  solidifies, 
the  function  of  the  testicle  being  destroyed  if  this  process  be  exten- 
sive.    Such  a  testicle  is  apt  to  be  the  seat  of  chronic  difficulty. 

What  is  the  treatment? 

The  prognosis  is  grave,  and  energetic  measures  must  be  resorted 
to  to  prevent  destruction  of  the  testicle.  Rest  in  the  recumbent 
position  with  a  support  of  the  organ  is  essential.  If  the  case  be 
seen  early,  antiphlogistic  measures  should  be  adopted :  the  applica- 
tion of  leeches  around  the  abdominal  ring  or  incisions  into  the  large 
scrotal  veins,  with  a  relaxation  of  the  parts  by  hot  douching  or 
sitz-bath,  tobacco  poultices  constantly  applied,  with  the  testicle 
supported  and  the  bowels  kept  well  drained.  If  these  measures 
fail  to  abate  the  inflammation,  and  suppuration  or  gangrene  is 
suspected,  incision  should  be  resorted  to  without  delay,  making 
the  endeavor  to  freely  drain  the  affected  organ.  If  a  fistula  be 
left,  it  may  be  opened  by  a  deepening  incision  and  the  track  be 


156  DISEASES  OP  THE  TESTICLE. 

scraped  and  treated  with  stimulating  dressings.  If  a  fungus  or 
liernia  of  the  testicle  appears,  it  may  be  either  tied  off  or  cauter- 
ized, or,  if  no  other  disease  remains,  be  replaced  and  the  edges  of 
the  wound  brought  together  and  sewed.  In  old  cases  the  disease 
may  be  so  extensive,  the  testicle  indurated  and  containing  fistulae 
and  fungi,  that  extirpation  is  often  advisable ;  especially  in  debili- 
tated subjects  it  is  advisable  to  remove  a  source  of  unhealthy 
absorption   which   causes  a   continual   wearing  on  the  system. 

EPIDIDYMITIS. 
What  are  the  causes  of  epididymitis  ? 

Inflammation  of  the  urethra  is  the  most  common  cause,  or  any 
undue  irritation  or  congestion  of  the  urethra  may  be  responsible 
for  it,  as  prolonged  sexual  excitement,  instrumental  examinations, 
etc.  The  most  common  cause  of  an  epididymitis  is  gonorrhoeal 
inflammation  and  its  results,  such  as  stricture,  prostatitis,  etc.,  in 
which  class  of  cases  inflammation  existing  around  the  prostatic 
sinus  near  the  ejaculatory  ducts  travels  down  the  mucous  membrane 
to  the  epididymis.  That  the  resulting  epididymitis  is  an  extension 
of  inflammation,  and  not  a  reflex  irritation,  seems  to  be  borne  out 
by  the  fact  that  it  generally  occurs  in  the  later  periods  of  a  gonor- 
rhoea, unless  instrumental  interference  has  been  resorted  to,  and  not 
during  the  early  stages,  when  the  inflammation  has  not  reached  the 
deep  urethra.  That  epididymitis  is  a  result  of  reflex  irritation  is 
claimed  by  some,  but  this  probable  fallacy  has  been  made  from  the 
fact  that  inflammation  will  travel  so  rapidly  through  the  vas  defe- 
rens as  to  leave  no  trace  of  its  course  and  reveal  no  symptoms  except 
in  the  epididymis.  In  all  cases  of  epididymitis  from  whatever  cause 
it  probably  can  be  safely  assumed  that  there  exists  a  congestion  or 
latent  inflammation  in  the  region  of  the  prostatic  sinus. 

What  are  the  symptoms? 

They  may  be  acute  or  subacute  at  the  onset.  A  previous  attack 
is  apt  to  ensure  a  mild  subsequent  one.  At  first  a  feeling  of  un- 
easiness is  referred  to  the  testicle,  running  up  the  cord  and  felt  in 
the  back,  with  a  certain  amount  of  tension  in  the  groin,  which  is 
generally  spoken  of.  Sometimes  a  chill  and  febrile  affections  share 
in  the  manifestations,  but  these  are  not  as  frequent  as  in  orchitis. 
Within  a  short  time,  probably  a  few  hours,  there  is  a  pronounced 
pain  felt  in  the  testicle,  which  rapidly  increases  in  size,  varying  ac- 
cording to  the  acuteness  of  the  case  and  in  different  individuals. 


EPIDIDYMITIS.  157 

Examination  reveals  the  tension  and  heat  of  the  testicle,  and  es- 
pecially the  hotness  of  the  epididymis.  In  the  mild  cases  the 
changes  are  for  the  most  part  entirely  confined  to  the  epididymis, 
but  in  severe  acute  attacks  the  symptoms,  being  all  aggravated, 
occur  with  greater  rapidity  and  are  more  intense.  A  periorchitis 
intervenes,  resembling  an  inflammatory  oedema.  Fluid  may  occur 
in  the  tunica  vaginalis  of  a  serous  or  sero-sanguinolent  character, 
causing  its  distension  and  increasing  the  pain.  The  scrotal  tissues 
may  also  become  inflamed  and  oedematous,  and  with  such  surround- 
ing swelling  and  inflammation  the  epididymis  will  be  very  difficult 
to  map  out.  The  cord  also  takes  part  in  the  inflammation,  and 
becomes  swollen  and  hard,  even  to  the  extent  of  becoming  strangu- 
lated, which  gives  rise  to  characteristic  symptoms — namely,  the  lo- 
calized pain  at  the  point  of  strangulation,  great  prostration,  vomit- 
ing, etc.  The  disease  advances  for  several  days,  and  the  symptoms 
intensify  as  the  swelling  increases.  After  remaining  stationary  for 
a  few  days,  it  begins  to  decline  and  the  intensity  of  the  symptoms 
to  diminish.  The  intense  pain  is  generally  the  first  symptom  to 
subside,  and  it  becomes  quite  bearable  while  in  the  recumbent 
posture,  even  when  the  organ  is  still  greatly  enlarged.  "With  the 
disappearance  of  the  pain  whatever  febrile  symptoms  accompany 
the  inflammation  also  subside. 

The  course  of  the  disease  has  a  natural  limit  of  about  two  weeks, 
while  relapses  are  easily  brought  on  by  carelessness  and  neglect. 
The  hardness  in  the  epididymis,  however,  remains  for  a  long  time 
after  the  above  period,  and  disappears  slowly,  for  months  and  even 
years.  In  some  cases  it  never  entirely  disappears.  Suppuration 
is  rare,  although  it  occurs  in  epididymitis.  Atrophy  does  not  occur 
unless  the  secreting  substance  of  the  testicle  is  also  involved  by 
inflammation  as  a  true  orchitis  instead  of  by  an  inflammatory  oedema. 
The  inflammation  which  is  left  behind  disappears  from  the  head 
first,  and  last  from  the  tail. 

How  is  epididymitis  distinguished  from  orchitis? 

Epididymitis  is  a  common  affection,  having  as  its  origin  urethral 
inflammation  or  irritation.  Orchitis  is  rare,  caused  by  injury  or 
the  mumps,  sometimes  gout  or  cold.  The  pain  in  the  former  is  more 
bearable,  except  where  strangulation  of  the  cord  exists :  it  is  modified 
in  the  recumbent  position  and  by  support,  while  in  the  latter  it  is 
excruciating,  even  when  the  swelling  is  not  very  great,  and  position 
does  not  modify  it.     The  swelling  of  the  former  varies,  being  oval 


158  DISEASES   OF   THE   TESTICLE. 

or  roundisli,  and  sometimes  irregular.  Of  the  latter  it  is  oval. 
In  the  former  the  epididymis  is  indurated  and  tender,  and  except 
during  the  most  acute  stage  may  be  mapped  out,  while  in  the  lat- 
ter it  is  not  distinguishable  at  all.  In  the  former  the  body  of  the 
testicle  may  be  normal  or  sometimes  sensitive  and  hard,  but  not  to 
so  marked  a  degree  as  in  orchitis.  In  the  former  there  is  always 
fluid  in  the  tunica  vaginalis,  rarely  in  the  latter.  In  epididymitis 
constitutional  symptoms  are  slight,  and  it  terminates  in  resolution, 
leaving  slight  thickening  in  the  epidid3'^mis,  generally  in  the  tail ; 
in  the  latter  constitutional  symptoms  are  more  marked ;  it  termi- 
nates in  resolution,  but  is  more  subject  to  abscess,  gangrene,  chronic 
hardness,  or  atrophy. 

Does  sterility  sometimes  occur  after  epididymitis  ? 

Yes,  when  both  testicles  have  been  attacked,  and  the  remaining 
induration  is  suJQ&cient  to  obliterate  the  communication  of  the  canal 
of  the  epididymis  with  the  secreting  portion  of  the  testicle.  This 
may  be  more  readily  effected  in  the  tail  than  in  the  head  of  the 
epididymis,  as  in  the  former  situation  there  exists  only  one  con- 
voluted tube,  while  in  the  latter  there  are  several.  It  is  in  the  tail 
that  induration  is  most  frequently  of  a  permanent  nature.  Cases 
which  are  sterile  on  this  account  retain  their  full  sexual  vigor,  and 
the  condition  becomes  only  known  by  examination  of  the  seminal 
fluid  and  absence  of  spermatozoa  is  detected. 

What  is  the  treatment  of  epididymitis? 

The  prophylactic  treatment  during  the  course  of  a  gonorrhoea  is  to 
properly  support  the  testicle  and  to  observe  such  measures  as  are 
laid  down  in  the  treatment  of  urethral  inflammations  to  prevent 
the  occurrence  of  this  and  other  complications,  such  as  abstinence 
from  sexual  intercourse,  alcoholic  stimulants,  and  all  substances 
which  tend  to  render  the  urine  irritating.  When  the  disease  occurs 
the  indications  are  rest  in  the  recumbent  position,  with  proper  sup- 
port for  the  inflamed  organ,  which  in  mild  cases  may  be  sufiicient 
to  induce  the  symptoms  to  subside.  In  the  more  acute  cases  these 
measures  must  be  accompanied  by  local  applications  of  moist 
heat,  as  may  be  afforded  by  flaxseed  and  tobacco  poultices.  These 
should  be  applied  constantly  at  short  intervals,  so  as  to  ensure  a 
continuance  of  the  heat  with  little  interval.  In  the  aggravated 
cases,  where  the  pain  is  extreme  and  the  cord  perhaps  becomes 
strangulated,  ten  or  fifteen  leeches  may  be  applied  to  the  groin  with 
excellent  effect,  or  if  the  intense  pain  is  referable  to  the  great  dis- 


TUBERCULOUS   DISEASE   OF   THE   TESTICLE.  159 

tension  of  the  tunica  vaginalis,  puncture  of  this  sac  will  be  followed 
by  striking  relief. 

In  regard  to  internal  medication  rational  measures  should  be 
adopted,  such  as  the  use  of  laxatives  and  alkalines,  besides  which 
the  administration  of  the  tincture  of  ph3^tolacca  decandra,  in  from 
10  to  15  minim  doses  every  three  or  four  hours,  has  generally  the 
eiFect  of  causing  a  subsidence  of  the  acute  symptoms.  If  this  is 
not  successful,  anodynes  must  be  resorted  to  until  the  acute  stage 
is  passed.  After  this  period  we  have  the  swelling  to  cope  with, 
and  this  is  properly  dealt  with  by  carefully  applied  straps,  consist- 
ing of  adhesive  plaster,  evenly  and  uniformly  placed  so  as  to  pro- 
duce a  uniform  pressure  on  the  swelling  of  the  affected  organ.  One 
application  of  these  straps  is  sometimes  sufficient,  but  they  may 
soon  become  loose  and  be  of  no  service  from  a  reduction  of  the 
swelling,  and  a  new  set  must  be  applied.  During  the  course  of  an 
acute  gonorrhoea  it  is  well  to  stop  all  other  treatment.  In  a  re- 
lapsing deep  urethritis,  however,  the  instillation  of  a  few  drops  of 
a  mild  solution  of  nitrate  of  silver  is  often  very  effective  in  pro- 
ducing a  cure. 

TUBERCULOUS  DISEASE   OF  THE  TESTICLE. 

In  what  different  forms  does  it  appear? 

Either  as  a  tuberculosis  occurring  spontaneously  in  the  testicle 
or  as  an  after-occurrence  to  previous  disease  remaining  as  a  degener- 
ation or  inflammatory  thickening.  The  latter  is  a  slow,  mild  inflam- 
mation, which  is  apt  to  occur  during  a  chronic  urethral  discharge. 
The  epididymis  becomes  swollen,  nodular,  and  sensitive.  It  may 
take  on  caseous  degeneration.  It  has  been  termed  pseudo-tuber- 
cular epididymitis,  but  if  it  becomes  advanced  and  is  not  arrested 
the  disease  resembles  in  every  way  the  true  tubercular  disease 
which  comes  on  without  local  cause  and  is  not  necessarily  associ- 
ated with  any  urethral  disease.  The  true  tubercular  testicle  occurs 
in  strumous  subjects,  who  are  apt  to  show  evidences  of  the  disease 
elsewhere. 

What  are  the  symptoms? 

Examination  of  the  testicle  reveals  enlargement,  which  is  apt  to 
be  hard  and  lumpy  behind  or  throughout  the  organ.  The  epididy- 
mis is  primarily  affected  by  the  disease,  but  the  secreting  structure 
becomes  involved  later.  The  vas  deferens  may  also  be  affected  by 
the  disease  as  well  as  the  seminal  vesicles.    These  latter  can  be  felt 


160  DISEASES   OF   THE  TESTICLE. 

by  a  rectal  examination.  One  or  both  testicles  may  be  affected, 
and  if  this  be  the  case  the  sexual  power  is  apt  to  be  impaired.  The 
tubercular  nodules  form  around  the  seminal  tubes,  which  after  a 
variable  period  break  down  and  form  cheesy  masses.  During  the 
course  of  the  advancement  of  the  disease,  which  is  slow,  the  skin 
over  the  epididymis  becomes  oedematous  and  adherent ;  the  small 
cold  abscess,  if  allowed  to  discharge,  shows  a  cheesy  material. 
An  abscess  of  this  kind  which  is  opened  externally  is  apt  to  remain 
permanently  fistulous. 

What  is  the  treatment? 

The  treatment  is  constitutional  and  hygienic,  as  employed  to 
check  tubercular  disease  elsewhere.  Support  of  the  testicle  is  also 
necessary.  If  abscess  forms  it  should  be  poulticed  and  opened. 
An  operation  performed  for  the  purpose  of  removing  the  diseased 
area  should  include  the  epididymis  only,  except  where  the  rest  of 
the  testicle  is  disorganized,  when  castration  becomes  necessary. 

SYPHILITIC   TESTICLE. 

What  are  the  syphilitic  affections  of  the  testicle  ? 

Syphilitic  epididymitis  and  syphilitic  orchitis.  The  former  ap- 
pears in  the  early  months  of  the  disease  during  the  period  of  the 
early  eruptions.  It  is  confined  to  the  epididymis,  and  mainly  to 
the  globus  major.  It  is  usually  bilateral.  It  is  distinguishable  from 
chronic  epididymitis  as  affecting  the  head  and  not  the  tail,  where 
the  latter  disease  is  generally  seated,  and  stands  out  as  a  clearly- 
defined  swelling  distinct  from  the  testicle.  Finally  it  succumbs  to 
the  internal  treatment  of  syphilis.  No  local  measures  are  required. 
Syphilitic  orchitis  appears  in  two  different  forms,  either  as  a  diffuse 
interstitial  inflammation  or  as  gummy  nodules.  Diffuse  syphilitic 
orchitis,  like  interstitial  inflammations  in  other  organs,  attacks  the 
fibrous  structure  of  the  testicle,  which  increases  and  proliferates 
so  as  to  impinge  upon  the  secreting  structure  and  cause  atrophy. 
The  organ  is  greatly  enlarged,  its  tunics  become  hypertrophied, 
and  fluid  collects  in  the  tunica  vaginalis.  One  or  both  testicles 
may  be  affected  simultaneously  or  consecutively.  After  a  time 
contraction  sets  in  at  the  expense  of  the  secreting  structure,  and 
the  organ  becomes  greatly  diminished  in  size.  If  the  process  has 
only  affected  a  portion  of  the  testicle,  the  contraction  in  this  portion 
will  cause  a  depression  at  the  point  involved. 

The  gummatous  form  of  syphilitic  testicle  may  coexist  with  the 


SYPHILITIC   TESTICLE.  161 

diflfuse,  and  is  often  spoken  of  as  an  aggravation  of  the  disease.  It 
is  characterized  by  the  appearance  of  gummy  nodules  of  variable 
size,  which  consist  of  a  collection  of  cells  undergoing  fatty  degen- 
eration, fastened  together  by  fibrous  tissue.  They  are  nourished 
by  a  grayish  vascular  areola,  and  as  they  increase  in  size  have  a 
tendency  to  soften  in  the  centre.  They  may  form  near  the  surface 
or  in  the  substance  of  the  gland.  The  epididymis  is  less  apt  to  be 
aflfected,  and  the  vas  deferens  rarely.  The  tunica  vaginalis  is  more 
or  less  distended  with  fluid,  and  the  membrane  itself  is  apt  to  be 
thickened.  The  testicle  becomes  enlarged  to  a  considerable  extent 
when  the  two  forms  of  disease  coexist.  The  ultimate  course  of 
these  gummy  nodules  is  to  soften,  become  entirely  absorbed,  or  to 
calcify,  causing  complete  or  only  partial  atrophy  of  the  testicle,  or 
the  integument  over  those  near  the  surface  may  become  adherent 
and  ulcerate,  resulting  in  a  fungus,  which  consists  in  a  bulging  out 
of  the  tubular  structure  of  the  organ,  this  being  permitted  by  ulcera- 
tion of  the  intervening  structures.  Syphilitic  orchitis  generally  does 
not  appear  until  after  the  third  year  of  syphilis,  although  occasion- 
ally before  this  period.  The  growth  of  the  testicle  occurs  slowly  and 
without  pain,  unless  there  be  a  small  amount  of  new  growth  along 
the  cord.  On  examination  the  testicle  will  be  found  to  be  greatly 
enlarged,  several  times  its  natural  size ;  it  may  be  very  smooth  and 
hard,  or  the  body  may  be  irregular  and  nodular,  showing  softened 
spots.  If  only  a  portion  of  the  organ  be  involved,  the  healthy  part 
will  be  normally  sensitive.  A  syphilitic  testicle  is  insensible  to 
pressure.  The  vas  deferens  is  very  rarely  involved,  as  well  as  the 
scrotal  tissues,  primarily,  so  that  the  hardened  lump  is  freely 
movable.  The  tunica  vaginalis  contains  fluid,  which  is  sometimes 
sufficient  to  destroy  the  outline  of  the  testicle,  and  its  removal 
becomes  necessary  to  make  proper  examination. 

The  prognosis  is  good  when  the  disease  is  put  under  antisyphi- 
litic  treatment,  to  which  it  readily  succumbs.  The  gummatous  mate- 
rial becomes  absorbed  and  the  pressure  is  taken  away  from  those 
tubules  which  have  not  already  been  destroyed  by  the  disease. 

What  is  the  treatment  ? 

The  early  form  of  syphilis  of  the  testicle  which  appears  in  the 
epididymis  gets  well  rapidly  under  mercury.  For  the  syphilitic 
orchitis  the  mixed  treatment,  mercury  and  iodide  of  potash,  is  more 
applicable.  The  later  disease  appears  after  the  period  of  chancre 
the  more  useful  will  the  iodide  be  found,  or  when  the  disease  has 
11— G-U. 


162  DISEASES   OF   THE   TESTICLE. 

been  very  destructive  and  fungus  is  present,  the  most  rapid  effect 
is  to  be  obtained  by  pushing  rapidly  with  increasing  doses  the  iodide 
of  potash  or  soda,  resorting  to  a  combination  with  mercury  after 
considerable  effect  has  been  produced.  No  local  treatment  is  neces- 
sary. The  fungus  should  not  be  cut  away,  as  some  healthy  tubules 
may  become  sacrificed.  It  may  be  compressed  in  place  by  the  use 
of  straps  after  any  constriction  of  the  tissues  at  its  neck  has  been 
divided. 

TUMOBS  OF  THE  TESTICLE. 

"What  tumors  are  found  affecting  the  testicle  and  surrounding 
tissues  ? 

Soft  and  solid  tumors.  The  soft  consist  of  the  regular  varieties 
of  cystic  tumors,  and  are  either  malignant  or  non-malignant.  The 
former  are  sarcoma  or  carcinoma  with  cystic  degeneration  ;  the  lat- 
ter are  in  many  cases  dilatations  of  the  secreting  structure  of  the 
organ  which  have  become  separated  and  surrounded  by  individual 
capsules.  It  is  difficult  to  distinguish  always  between  the  malig- 
nant and  non-malignant  cystic  tumors  of  the  testicle.  Examina- 
tion of  the  fluid  may  reveal  the  presence  of  cancer-cells. 

The  only  treatment  to  be  advanced  is  the  removal  of  the  affected 
organ.  Dermoid  cysts  have  been  found  in  the  scrotum  contain- 
ing skin,  hair,  bone,  teeth,  etc. 

What  solid  tumors  of  the  testicle  occur  ? 

Sarcoma  and  lympho-sarcoma  and  carcinoma  of  the  scirrhous  and 
encephaloid  types.  The  indurated  fibrous  mass  which  is  often  left 
after  inflammation  of  the  testicle  sometimes  enlarges  and  forms  a 
fibrous  tumor.  Likewise  after  a  chronic  orchitis  or  other  diseases 
of  the  testicle  calcareous  lumps  occur.  They  may  be  deposited  in 
the  epididymis  or  the  vas  deferens.  These  various  growths  of  the 
testicle  call  for  the  operation  known  as  castration,  which  should  be 
resorted  to  as  early  as  possible,  especially  in  the  case  of  cancer, 
before  the  cord  becomes  enlarged  and  the  lumbar  glands  involved. 

How  is  the  operation  of  castration  performed  ? 

The  patient  being  anaesthetized,  the  parts  are  carefully  shaved. 
An  incision  is  made  from  the  external  abdominal  ring  down  to  the 
bottom  of  the  scrotum  anteriorly,  and  the  different  layers  of  tissues 
cut  through  until  the  testicle  is  reached.  Bleeding  points  should 
be  seized  as  they  occur,  and  the  testicle  is  torn  away  from  its  adhe- 
sions.    The  cord  is  tied  by  a  stout  ligature  high  up,  and  then  cut 


NEUROSES   OF   THE   TESTICLE.  163 

below  the  ligature,  having  been  previously  seized  and  held  to  pre- 
vent its  drawing  up.  The  arteries  of  the  cord  should  be  ligated 
separately  with  catgut  ligatures,  when  the  single  ligature  around 
the  entire  cord  may  be  released.  Any  tightly  adherent  skin  over 
the  testicle  should  also  be  removed  in  case  of  malignant  disease, 
and  the  wound  drained  and  dressed  antiseptically. 

NEUROSES   OF   THE   TESTICLE. 

What  neuroses  of  the  testicle  commonly  present  themselves  ? 

Irritable  testicle  and  neuralgia  of  the  testicle.  The  latter  is 
more  or  less  an  aggravation  of  the  former,  being  deeply  seated. 
The  former  is  caused  by  sexual  excesses  in  the  young  who  stimu- 
late their  sexual  appetites  in  a  pernicious  manner,  and  who  are 
unable  to  give  vent  to  them  in  the  natural  way. 

The  treatment  is  hygienic,  and  in  debilitated  subjects  the  use  of 
tonics,  etc.  Unstimulating  diet  should  be  adopted,  and  the  removal 
of  the  exciting  cause,  if  possible,  effected.  These  diseases  are 
sometimes  accompanied  by  neuralgia  of  the  prostatic  urethra, 
which  should  be  treated  accordingly. 

Neuralgia  of  the  testicle  varies  in  severity.  The  pain  is  not  so 
superficial  as  in  irritable  testicle,  and  it  may  be  so  severe  as  to 
cause  retraction  and  reflex  symptoms,  such  as  vomiting,  irritability 
of  the  bladder,  etc.  The  cause  of  this  condition  is  difficult  to  settle 
upon.  In  a  general  way  there  is  apt  to  exist  a  predisposition  in 
the  sexual  temperament,  when  it  may  be  due  to  the  same  causes 
as  produce  neuralgia  elsewhere,  such  as  malaria,  syphilis,  etc. 
It  may  follow  injury  or  orchitis,  and  sometimes  is  referable  to  an 
affection  of  the  deep  urethra  or  some  other  part  of  the  genito- 
urinary tract.  The  pain  is  sometimes  constant,  at  other  times 
intermittent.     It  is  of  an  acute,  lancinating  character. 

What  is  the  treatment  ? 

If  any  cause  can  be  discovered  elsewhere  in  the  genito-urinary 
tract,  it  should,  of  course,  be  removed.  The  treatment  may  be 
sedative,  in  the  use  of  belladonna  or  aconite  externally  or  the  use 
of  cold  douching  or  ice-bag  constantly  applied.  The  most  rational 
method  of  treatment  is  hygienic,  which  means  that  if  the  sexual 
appetite  cannot  be  kept  within  bounds  and  controlled  unsatisfied, 
marriage  is  the  essential  antidote. 


164  DISEASES   OF   THE   TESTICLE. 

IMPOTENCE. 

What  maladies  involve  the  genital  function? 
,  I.  Certain  neuroses  which  are  merely  functional,  such  as  false 
impotence,  nocturnal  emissions,  etc. ;  II.  True  impotence  and  ster- 
ility. 

What  is  impotence  ? 

A  lack  of  power  to  properly  perform  the  sexual  act.  It  does 
not  imply  a  defect  in  the  semen,  which  is  sterility.  We  have  two 
forms  of  impotence,  one  of  which  comes  under  the  head  of  a  neu- 
rosis, /aZse  impotence.,  and  the  other,  true  impotence^  depends  upon 
the  physical  development  of  the  parts. 

What  are  the  conditions  which  may  produce  true  impotence  ? 

Abnormalities  of  the  penis  ;  minute  and  extreme  size  of,  absence 
of;  extreme  epispadias  and  hypospadias;  superabundant  prepuce 
with  tight  orifice ;  growths  around  or  about  the  penis  ;  elephantiasis  ; 
curves  of  the  penis,  the  after-efi"ects  of  injuries;  swellings  in  the 
surrounding  parts,  such  as  hydrocele,  hernia ;  stricture  of  the 
urethra,  which  interferes  with  the  proper  ejaculation  of  the  semen ; 
or  ejaculation  of  the  semen  backward  into  the  bladder,  caused  by 
the  faulty  direction  of  the  ejaculatory  ducts.  It  sometimes  comes 
on  after  the  operation  for  stricture  by  external  urethrotomy.  It 
may  also  be  symptomatic  of  certain  diseases,  when  it  is  only  tem- 
porary, as  the  sexual  power  returns  with  removal  of  the  disease. 
As  such  causes  may  be  named  the  acute  febrile  diseases,  various 
cachexia,  syphilitic  testicle,  severe  varicocele,  spermatorrhoea,  etc., 
and  also  general  corpulency.  All  of  the  above-named  causes  pro- 
duce "  organic  impotence,"  in  which,  while  there  may  be  a  natural 
ejaculation  of  semen,  there  is  a  failure  to  properly  introduce  the 
penis  or  deposit  the  semen  in  the  upper  part  of  the  vagina.  They 
do  not  involve  sterility,  as  the  other  genital  organs  may  be  per- 
fectly normal :  the  fact  that  the  semen  can  be  deposited  at  all 
within  the  vagina  means  that  impregnation  may  take  place. 

The  treatment  of  true  impotence  involves  the  removal  of  the 
cause  producing  the  physical  disability,  be  it  deformity  or  disease. 

Upon  what  does  false  impotence  depend? 

This  condition  is  psychical,  and  depends  more  or  less  upon  the 
mind  or  nervous  temperament  of  the  patient.  It  may  be  due  to 
nervousness,  moral  perversion,  or  it  may  be  a  weakness  with  irrita- 
bility  of  the   prostatic  urethra.     These   different  forms   of  false 


IMPOTENCE.  165 

impotence  are  referable  to  different  causes,  and  have  different  ways 
of  thrusting  themselves  upon  the  unhappy  patient.  The  simplest 
form  is  found  in  nervous  individuals  who  are  perhaps  candidates 
for  marriage,  and  at  the  arrival  of  the  moment  for  consummation 
they  are  either  unable  to  get  an  erection,  or  erection  exists  and  ejac- 
ulation has  taken  place  before  the  act  can  be  accomplished.  This 
form  is  simply  a  lack  of  confidence,  and  is  readily  overcome  by  the 
patient,  who,  in  spite  of  what  may  have  occurred,  continues  to  act 
naturally  in  endeavoring  to  accomplish  his  end. 

Almost  the  same  condition  may  be  produced  in  those  who  have 
masturbated  excessively  in  early  youth,  or  who  have  had  gonor-  • 
rhoea  which  has  been  accompanied  by  a  chronic  cystitis  or  prosta- 
titis. This  condition,  is  again  produced  by  a  moral  perversion  in 
those  who  have  masturbated  excessively  or  have  been  dissipated  in 
early  youth,  who  when  married  find  themselves  incapable  of  per- 
forming their  conjugal  duties,  and  yet  the  thought  of  immoral 
means  stimulates  their  desires  or  they  are  fully  competent  to 
accomplish  them  with  prostitutes.  A  species  of  this  form  of  impo- 
tence has  been  described  as  relative  impotence,  where  the  individual 
has  a  sexual  aversion  except  to  certain  women.  It  is  unfortunate 
when  it  exists  toward  the  patient's  own  wife,  and  is  often  one  of 
the  evil  effects  of  the  •'  marriage  de  convenance." 

Impotence  due  to  excessive  irritahility  shows  itself  in  an  inability 
to  obtain  erection  at  the  proper  time  or  in  erection  accompanied  by 
premature  ejaculation.  This  form  is  found  in  those  who  are  possessed 
of  an  exceedingly  amorous  disposition,  and  who  suffer  from  a  con- 
tinually ungratified  and  uncontrollable  sexual  desire,  or  who  have 
practised  the  vice  of  masturbation  and  are  troubled  with  numerous  "" 
sexual  emissions.  Examination  of  the  urethra  by  a  sound  will 
reveal  an  excessively  sensitive  prostatic  urethra,  the  introduction 
being  almost  unbearable.  Sometimes  it  is  accompanied  by  the 
discharge  of  a  glairy,  starch-like  material  from  the  urethra,  often 
expelled  at  stool  and  seen  by  the  patient,  much  to  his  discom- 
fort, it  being  supposed  by  him  to  be  spermatorrhoea,  with  which  it 
is  frequently  often  confounded  by  the  physician. 

What  is  the  treatment  of  impotence? 

The  treatment  of  this  malady  varies  according  to  the  form  in 
which  it  presents  itself.  As  the  organic  impotence  requires  a  re- 
moval of  the  physical  obstacle  which  produces  it  or  the  treatment 
of  the  disease  or  cachexia  which  has  preceded  it,  so  that  form 


166 


DISEASES   OF   THE   TESTICLE. 


which  is  largely  due  to  an  extreme  irritability  around  the  prostatic 
sinus  requires  a  certain  amount  of  deep  urethral  medication. 
Those  causes  of  impotence  which  are  included  under  the  head  of 
"  functional  "  which  the  physician  has  to  deal  with  are  either  en- 
tirely psychical  in  their  character  in  neurotic  subjects  or  are  the 
result  of  weakness  which  is  due  to  an  excessive  irritability,  having 
been  occasioned  by  past  excesses  and  indulgences.  Into  both  forms 
there  is  sure  to  enter  a  neurotic  element,  and  in  both  forms  there  is 
apt  to  be  some  local  congestion,  at  least.  The  milder  of  these 
psychical  cases  get  well  of  themselves  when  the  causes  upon  which 
they  depend  disappear  or  are  removed.  Time  alone  is  the  most 
powerful  and  effective  means  which  can  be  brought  into  service  for 
the  benefit  of  these  cases.  When  they  come  within  the  notice  of 
the  physician,  it  requires  a  delicate  tact  and  a  most  careful  judg- 
ment, not  to  say  patience,  to  treat  them  with  any  degree  of  credit- 
able success.  It  requires  the  full  tact  of  the  physician  and  the 
co-operation  of  the  patient,  and  in  order  to  obtain  the  patient's  co- 
operation the  physician  must  be  sure  of  his  confidence.  As  already 
stated,  these  cases  are  largely  psychical,  and  have  a  decided  neu- 
rotic element  in  their  causation  ;  hence  those  who  are  not  prepared 
to  receive  them  and  to  bear  with  them  as  such  might  better  refuse 
to  deal  with  them  on  the  start.  In  general,  the  observation  of 
hygiene  is  important.     Out-door  exercise  in  the  country,  cold  bath- 

FiG.  19. 


Psychrophor. 


ing,  and  tonics  are  useful.  The  use  of  such  aphrodisiacs  as  cantha- 
rides.  damiana,  and  phosphorus  should  be  resorted  to  as  the  case 
-may  require.     The  local  treatment  is  important,  and  should  consist 


ANOMALIES    AFFECTIXG   THE  SEMEX.  167 

in  the  passage  of  cold  metallic  sounds,  full  size,  which  are  allowed 
to  remain  from  five  to  ten  minutes,  or  the  cold  sound  called  the 
"  psychrophor,"  which  provides  for  the  continual  passage  of  cold 
water  through  its  interior,  having  a  closed  end  at  its  lower  ex- 
tremity and  two  arms  externally.  Astringent  applications  are  also 
used  with  good  effect,  such  as  glycero-tannin  and  instillations  of 
nitrate-of-silver  solutions.  Finally,  electricity  has  its  adaptation  in 
those  cases  where  there  is  a  lax  condition  of  the  muscular  fibres 
surrounding  the  bulb  of  the  urethra,  allowing  a  dribbling  of  the 
semen  at  the  end  of  the  sexual  act  instead  of  producing  a  proper 
ejaculation.  In  its  use  one  pole  may  be  put  in  the  rectum  and  the 
other  placed  on  the  raphe  of  the  perineum.  A  faradic  current 
should  be  adopted. 

ANOMALIES  AFFECTING  THE  SEMEN. 
What  is  sterility? 

Sterility  implies  an  afi'ection  of  the  seminal  fluid,  an  entire  ab- 
sence or  lack  of  the  vital  elements. 

What  are  the  causes  ? 

Degeneration  or  atrophy  of  both  testicles. 

What  is  aspermia? 

Absence  of  semen.  It  is  either  congenital  or  acquired.  In  the 
latter  form  both  ejaculatory  ducts  become  occluded,  the  result 
generally  of  disease  of  the  prostate.  There  occurs  occasionally  a 
temporary  aspermia  with  an  apparently  normal  sexual  apparatus. 
It  may  last  a  few  weeks  or  months.  It  occurs  in  nervous  indi- 
viduals or  in  those  who  are  not  of  a  nervous  temperament  but  who 
are  suffering  from  the  effects  of  venereal  excesses.  These  same 
causes  which  may  contribute  to  make  a  man  impotent  may  produce 
aspermia. 

The  condition  termed  'polyspermia^  which  consists  in  a  consider- 
able increase  in  the  amount  of  semen,  rarely  occurs.  The  condition 
called  oligospermia^  denoting  a  small  quantity  of  semen,  occurs  in 
advanced  age  after  inflammation  of  the  testicles  and  prostate,  which 
only  partially  occludes  the  orifice  of  the  ducts. 

What  is  complete  absence  of  the  spermatozoa  called  ? 

Azoospermia.  It  may  be  either  congenital  or  acquired.  The  con- 
genital condition  implies  anomalies  of  the  testicle  or  cord.     The 


168  DISEASES   OF   THE   TESTICLE. 

acquired  form  generally  follow  inflammation  of  the  testicle  and 
cord. 

What  is  the  treatment  of  sterility  ? 

Sterility  in  the  male  does  not,  as  a  rule,  present  a  very  favorable 
prognosis,  as  removal  of  the  cause  is  not  apt  to  be  practicable.  If 
the  semen  is  blood-tainted  or  mixed  with  pus,  disease  of  the  pros- 
tatic urethra  or  neck  of  the  bladder  may  be  suspected,  and  in  such 
cases  a  5  per  cent,  solution  of  nitrate  of  silver  by  means  of  a  deep 
urethral  syringe,  5  to  10  minims  at  a  time,  can  probably  be  used 
with  best  effect. 

NOOTURNAIi  EMISSIONS. 

What  are  the  causes  of  emissions  ? 

They  occur  in  moderation,  and  naturally  as  a  result  of  over-dis- 
tended seminal  vesicles,  after  the  period  of  puberty  or  in  married 
individuals  who  are  temporarily  separated  from  their  wives.  They 
occur  with  unnatural  frequency  in  those  who  have  over-stimulated 
their  sexual  desire  by  continual  masturbation  and  excessive  venery, 
so  as  to  promote  a  continued  distension  in  the  seminal  vesicles. 

What  is  the  treatment  of  frequent  "  pollution  "  ? 

Nocturnal  emissions  which  only  occur  two  or  three  times 
weekly  may  be  more  or  less  disregarded,  so  far  as  treatment 
is  concerned,  and  if  the  thoughts  of  the  individual  be  properly 
directed  they  will  probably  disappear  of  themselves.  Where  they 
occur  several  times  nightly  and  for  a  considerable  period,  the 
mode  of  treatment  to  be  adopted  should  be  first  directed  toward  the 
general  health  of  the  patient,  and  such  hygienic  measures  as  cold 
bathing,  early  rising,  regular  muscular  exercise  to  produce  a  nat- 
ural fatigue  and  ensure  unbroken  rest  are  particularly  indicated. 
Lying  on  the  back  with  a  full  bladder  seems  to  favor  erection  and 
lead  to  emissions.  The  suggestion  of  tying  a  knotted  towel  in  the 
small  of  the  back  to  prevent  this  position  is  useful.  Bromide  of 
potash  and  lupulin  have  been  used  by  way  of  internal  medication, 
besides  the  mineral  and  bitter  tonics,  as  the  condition  of  the  indi- 
vidual may  call  for.  Mechanical  measures  have  been  devised  to 
prevent  pollutions,  but  they  are  of  questionable  value,  and  have  a 
tendency  to  keep  the  mind  of  the  patient  upon  his  malady,  which 
is  apt  to  be  of  a  neurotic  nature.     When  examination  reveals  an 


SPERM  ATORRHCEA.  169 

irritable  condition  of  the  prostatic  urethra,  deep  injections  of  nitrate 
of  silver  may  prove  serviceable. 

Does  pollution  occur  during  the  day? 

Yes,  though  more  rarely  than  at  night,  and  generally  in  individ- 
uals suffering  from  prostatic  irritability  or  in  those  who  allow  their 
minds  to  dwell  upon  amorous  subjects.  The  sight  of  certain  women 
will  occasion  ejaculation. 

The  treatment  is  by  cold  sounds  and  astringent  applications  to  the 
prostatic  urethra.     A  long  foreskin  should  be  removed  if  present. 

SPERMATORRHCEA. 
What  is  spermatorrhoea? 

Spermatorrhoea  is  an  unnatural  escape  of  seminal  fluid  without 
orgasm  or  sexual  intercourse  at  various  times  during  the  day,  gene- 
rally induced  by  muscular  effort,  notably  at  stool. 

What  are  the  causes? 

It  results  from  excessive  masturbation  and  venereal  excesses 
generally,  but  any  continual  nervous  strain  upon  the  overtaxed 
nervous  temperament  may  produce  the  condition,  or  any  inflamma- 
tory trouble  leading  to  congestion  and  irritation  of  the  prostatic 
sinus  and  seminal  vesicles.  Deposits  in  the  urine  generally  and 
mucous  discharges  from  the  urethra  are  made  use  of  by  quacks  to 
represent  this  malady.  The  most  common  affection  liable  to  be 
confounded  with  it  by  the  patient  is  false  impotence,  accompanied 
by  a  discharge  of  mucilaginous  prostatic  fluid  resembling  in  appear- 
ance the  semen,  and  more  frequently  expelled  during  defecation. 
The  presence  of  spermatozoa  settles  the  diagnosis. 

What  are  the  general  symptoms  accompanying  true  spermator- 
rhoea? 

The  individual  is  generally  a  neurotic  subject,  has  a  soft  droop- 
ing look  to  the  eye,  complains  of  a  feeling  of  weight  in  the  prostatic 
region,  has  dyspepsia,  and  is  generally  distressed  about  his  sexual 
apparatus.  The  sexual  appetite  is  apt  to  be  excessive,  feeble,  or 
perverted.  Such  patients  tend  to  grow  thin,  poorly  nourished,  and 
hypochondriacal.  There  is  another  class  of  sperm atorrhoeics  who 
have  the  disease  and  do  not  know  it,  and  whose  minds  are  not  trou- 
bled with  the  idea  of  impotence  of  the  congenital  apparatus  at  all. 
In  the  gravest  cases  the  symptoms  continue  to  grow  worse,  the  tes- 
ticles become  small  and  flabby  and  sensitive,  and  the  veins  large  and 


170  DISEASES   OF   THE   TESTICLE. 

full.  The  semen  becomes  less  and  grows  thin  and  free  from  sper- 
matozoa. Finally,  the  patient  becomes  entirely  impotent  and  loses 
the  power  of  erection. 

What  is  the  treatment? 

Some  cases  get  well  without  any  treatment,  and  others  fail  to  be 
cured  in  spite  of  all  measures.  Hygienic  means  generally  should  be 
adopted — measures  employed  to  preoccupy  the  mind  of  the  individual 
and  improve  his  general  health,  with  the  endeavor  to  impress  upon 
him  that  it  is  not  the  discharge  of  semen  which  produces  the  damage, 
so  much  as  the  moral  effect  it  has  upon  his  nervous  constitution.  The 
best  local  measure  to  be  adopted  is  the  use  of  solutions  of  nitrate 
of  silver  of  increasing  strength  injected  into  the  deep  urethra  at 
intervals  of  a  week,  starting  with  1  grain  to  the  ounce  and  doubling 
the  strength  at  every  sitting  up  to  48  grains  to  the  ounce  or  a  10 
per  cent,  solution,  which  will  probably  produce  the  maximum  effect 
to  be  gotten  by  these  local  means.  Failing  in  this,  there  is  nothing 
further  to  do  but  to  advise  the  patient  to  possess  his  soul  in  patience 
and  trust  that  Nature  will  accomplish  the  cure  which  other  means 
have  failed  to  do. 

VARICOCELE. 

What  is  varicocele  ? 

As  its  name  implies,  it  consists  of  a  varicose  condition  of  the 
plexus  of  veins  within  the  scrotum  called  the  pampiniform  plexus 
and  the  veins  of  the  spermatic  cord.  It  is  a  malady  of  frequent 
occurrence,  and  is  said  to  exist  in  some  degree  in  10  per  cent,  of 
the  males  of  the  human  race.  It  is  only  when  accompanied 
by  impressive  symptoms  that  it  is  called  to  the  notice  of  the 
physician. 

On  which  side  is  it  most  frequently  met  with? 

Almost  invariably  on  the  left  side.  Double  varicocele  often 
occurs ;  single  varicocele  of  the  right  side  is  infrequent. 

What  are  the  causes  of  this  condition  ? 

The  chief  cause  is  found  in  the  interference  with,  or  abuse  of,  or 
obstruction  to  the  proper  exercise  of,  the  physiological  function 
of  the  sexual  apparatus :  chiefly  is  it  seen  in  those  who  have 
erotic  fancies  and  amorous  temperaments,  who  encourage  rather 
than  curb  their  appetite,  which  is  compelled  to  remain  ungratified, 
and  in  those  who  keep  a  turgescence  of  the  veins  of  the  scrotum 


VARICOCELE.  171 

by  venereal  excesses  or  the  practice  of  masturbation.  The  slight 
varicocele  which  is  found  in  young  unmarried  men  is  only  a  tem- 
porary affair,  and  disappears  when  the  physiological  function  is 
allowed  the  proper  exercise.  The  causes  of  varicocele  occurring 
more  frequently  on  the  left  side  are  that  the  testicle  hangs  lower 
on  this  side,  and  the  fact  that  the  left  vein  empties  at  a  right 
angle  into  the  renal  vein  and  is  behind  the  sigmoid  flexure  of  the 
colon,  which  is  so  apt  to  be  distended  with  faecal  matter. 

Acute  varicocele  occurs  as  a  result  of  constant  straining  effort. 
It  may  last  for  several  weeks,  and  disappear  or  be  left  as  a  per- 
manent enlargement. 

What  are  the  symptoms  accompanying  varicocele  ? 

As  it  comes  on  slowly,  it  is  only  discovered  by  accident,  gen- 
erally when  it  has  assumed  a  good  size.  Pain  is  one  of  the  symp- 
toms which  accompany  it,  and  is  of  variable  character,  and  by  no 
means  depends  upon  the  size  of  the  varicocele.  A  very  large  vari- 
cocele may  be  attended  by  no  pain,  while  a  very  small  one  may  be 
the  source  of  a  great  deal  of  difficulty,  the  pain  running  up  the 
back  and  down  the  thighs.  The  mass  in  the  scrotum  feels  soft  and 
worm-like.  Atrophy  of  the  testicles  occurs,  although  seldom  as  a 
result  of  interference  with  the  circulation  after  varicocele  has  ex- 
isted for  a  considerable  time.  The  testicle  is  apt  to  be  more  or  less 
sensitive  to  pressure  with  this  condition  of  varicocele.  The  only 
other  symptoms  attending  it  are  those  which  relate  to  the  mental 
and  neurotic  condition  of  the  patient,  resulting  from  causes  which 
have  led  to  the  formation  of  the  condition,  and  amount  to  general 
hypochondria.  In  the  recumbent  position  the  swelling  of  vari- 
cocele generally  disappears  or  may  be  readily  reduced,  and  if  suf- 
ficiently strong  pressure  be  then  made  over  the  external  abdominal 
ring  and  the  standing  posture  assumed,  the  varicocele  will  not 
return  until  the  pressure  be  removed. 

What  is  the  treatment  of  varicocele  ? 

If  a  varicocele  is  accompanied  by  no  symptoms,  whether  it  be 
small  or  even  a  fair  size,  occurring  in  a  healthy  and  sensible  indi- 
vidual, there  is  no  reason  to  adopt  any  mode  of  treatment  except 
support  by  a  properly-fitting  suspensory  bandage.  Occurring  in 
young  bachelors  and  unmarried  men  who  suffer  from  ungratified 
sexual  desire,  marriage  is  the  antidote ;  otherwise  the  proper  treat- 
ment of  this  disorder  consists  either  in  wearing  continually  a  sus- 
pensory bandage  or  in  an  operation  for  its  radical  cure.     The  sus- 


172  DISEASES   OF   THE   TESTICLE. 

pensory  bandage  will  sometimes  be  sufficient  to  relieve  symptoms 
and  will  give  the  patient  a  degree  of  comfort  which  he  had  not 
before  experienced  ;  but  in  those  individuals  whose  condition  is  that 
of  hypochondriasis,  and  whose  minds  are  continually  reverting  to 
their  sexual  apparatus,  the  moral  effect  alone  of  an  operation  may 
be  conducive  to   considerable  benefit. 

What  operations  are  employed  for  the  radical  cure  of  varicocele  ? 

There  have  been  a  great  number  of  operations  devised  for  the 
cure  of  this  condition,  some  of  which  entail  a  cutting  procedure. 
In  the  author's  opinion  the  most  effective  operation,  the  most 
satisfactory  and  most  free  from  disagreeable  complications,  and  the 
most  rapid  of  cure,  is  the  subcutaneous  ligation  of  the  veins,  an 
operation  with  a  special  needle,  both  of  which,  the  operation  and 
the  needle,  have  been  perfected  by  Dr.  Edward  L.  Keyes. 

Fig.  20. 


Needle  for  Operation  on  Varicocele. 

Describe  the  steps  in  the  operation. 

The  patient  is  made  to  stand  up  beside  a  bed  or  table,  and  the 
varicocele  is  mapped  out  by  the  operator,  one  or  two,  and  perhaps 
three,  main  trunks  being  selected  for  ligation.  The  parts  are  made 
thoroughly  aseptic  with  a  1  :  1000  solution  of  bichloride  of  mer- 
cury. The  same  number  of  needles  as  there  are  veins  to  be 
ligated  are  threaded  with  heavy  twisted  silk,  which  has  been 
previously  carefully  prepared.  The  scrotum  is  seized  between  the 
thumb  and  index  finger,  and  the  vas  deferens  is  held  well  toward 
the  opposite  side.  The  different  punctures  are  made  with  the 
needles  between  the  veins  and  the  vas  deferens,  carrying  one  end 
of  the  silk  through  to  the  opposite  side.  The  silk  is  then  taken 
out  of  the  eye  of  the  needle,  the  eye  of  which  is  opened  from  the 
handle,  and  the  needle  pulled  back  to  its  point  of  entrance,  and  is 
then  made  to  worm  itself  between  the  dartos  and  the  veins,  and  to 
emerge  at  the  same  opening  as  made  before,  posteriorly.  The  end 
of  the  silk  is  reinserted  in  the  eye  and  pulled  back  completely 
through  the  anterior  opening.  By  holding  the  two  ends  of  the  silk 
firmly  in  one  hand  the  cellular  tissues  are  pulled  away  from  the 
loop  posteriorly  with  the  other.     All  hairs   around  the  opening 


VARICOCELE. — OPERATIVE   TREATMENT.  173 

made  by  the  puncture  are  removed,  and  the  silk  is  tied  forcibly  in 
a  triple  knot  cut  short  and  allowed  to  sink  into  the  scrotum.  This 
procedure  is  repeated  with  each  ligation.  The  patient  is  allowed 
to  lie  down  after  the  first  punctures  have  been  made,  as  following 
this  it  is  only  necessary  to  run  the  needle  close  to  the  dartos, 
irrespective  of  the  position  of  the  veins.  The  parts  should  be 
thoroughly  washed  again  with  the  bichloride  solution,  and  the 
scrotum  supported  in  a  suitable  bandage.  The  -pain  directly  after 
the  operation  is  not  generally  severe,  but  gradually  increases  in  the 
first  twenty-four  hours  or  so,  as  does  also  the  swelling.  Examina- 
tion will  reveal  the  formation  of  clots  above  the  ligatures,  which 
rapidly  become  firm  and  hard.  The  patient  may  go  about  as  soon 
as  the  pain  has  sufficiently  left  to  permit  his  doing  so  with  comfort. 
This  is  generally  at  the  end  of  four  or  five  days.  The  cure  of  the 
varicocele,  if  this  operation  be  properly  performed,  is  beyond  doubt. 
The  silk  ligature  remains  in  place  indefinitely,  becoming  encapsu- 
lated, and  eventually  absorbed.  In  one  or  two  instances  it  has 
gradually  found  its  way  to  the  surface  and  been  extracted,  in  which 
instances  cure  of  the  varicocele  has  been  as  usual.  Ablation  of  the 
scrotum  may  be  called  for  if  considerably  redundant,  in  which  case 
ligation  and  excision  of  the  larger  veins  may  be  more  properly 
performed  by  the  cutting  operation,  although  the  subcutaneous 
ligation  may  be  first  resorted  to,  and  at  a  later  day  ablation  of  the 
scrotum,  if  desired. 


INDEX. 


A. 

Abnormalities  of  the  urine,  144 

Administration  of  mercury,  27 

Alopecia,  24 

Anomalies  of  the  semen,  167 

Aspermia,  167 

Azoospermia,  167 

B. 

Balanitis,  80 
Bladder,  anatomy  of,  104 
anomalies  of,  105 
atony  of,  109-111 
atrophy,  105 
hernia  of,  105 
hypertrophy,  105 
morbid  growths,  111 
benign,  112 
malignant,  113 
paralysis  of,  109-111 
stone,  115 
relapse  of,  130 
Bubo,  syphilitic,  21 

c. 

Calculus,  urinary,  115 
Castration,  162 
Chancre,  19 

complications  of,  20 

different  forms  of,  20 

discharge,  20 
Chancroid,  32 

bubo  of,  34 
treatment,  35 

characteristics,  33 

complications  of,  33 

diflTerence  from  chancre,  34 

differential  diagnosis,  35 

treatment,  34 

G.  U. 


Chdrdee,  50 

symptoms,  51 

treatment,  51 
Circumcision,  83 
Cowperitis,  50 
Cowper's  glands,  50 
Cystitis,  107 

cantharides  as  cause  of,  108 

chronic,  108 
symptoms,  109 
treatment,  109 

symptoms,  107 

varieties  of,  107 
Cystoscope,  114 
Cystoscopy,  113 
Cysts  of  the  kidney,  140 

D. 

Dilatation,  62,  63.  67 
Diseases  of  the  testicle,  146 
Divulsion,  65 

E. 

Electrolysis,  66 
Emissions,  nocturnal,  168 
Endoscope,  47 
Enlarged  prostate,  87 

complications,  93,  94 

examination,  89,  90 

symptoms,  87,  88 

treatment,  91,  94 
Epididymitis,  156 

diagnosis  of,  from  orchitis,  157 

sterility,  158 

treatment,  158 
Extravasation  of  urine,  73,  75 

symptoms,  74 

F. 

Follicular  prostatitis,  98 


175 


176 


IKDEX. 


Follicular  prostatitis,  symptoms,  98 
Folliculitis,  50 

G. 

Genito-urinary  diseases,  37 
diagnosis  of,  75-79 
non-venereal,  75 
venereal,  37 
organs,  17 
Gleet,  41 
duration  of,  48 
microscope,  48 
neurotic  conditions,  49 
Gonococcus,  40 

means  of  determining,  40 
Gonorrhoea,  40 
complications  of,  50 
symptoms,  41 
treatment,  42-47 
Gonorrhceal  lymphangitis,  51 
rheumatism,  51 

different  forms  of,  52 
differential  diagnosis,  53 
seat  of,  52 
treatment,  53 

H. 

Hsematocele,  148 
Herpes  progenitalis,  84 

diagnosis,  85 
Hydrocele,  149 

acute,  149 

causes,  150 

chronic,  149 

congenital,  152 

fluid,  150 

of  the  spermatic  cord,  153 

treatment,  150 
injection,  151 
radical  cure,  150 
tapping,  150 
Hydronephrosis,  141 

differential  diagnosis,  142 

treatment,  142 

I. 

Impassable  stricture,  70 

treatment,  71,  72 
Impotence,  164 

treatment,  165 
Incontinence  of  urine,  106 


Iodides,  29 

Iritis,  syphilitic,  23 

K. 

Kidney,  anatomy  of,  131 
anomalies,  131 
cysts  of,  140 

treatment,  141 
diseases  of,  131 
syphilis  of,  142 
tuberculosis  of,  138 

L. 

Litholapaxy,  122 

complications,  124 
Lithotomy,  125-127 

complications,  130 
Lithotrity,  120 
Lymphangitis,  gonorrhceal,  51 

M. 

Mercury,  administration  of,  27 

Nephrectomy,  143 
Nephro-lithotomy,  143 
Nephrorrhaphy,  143 
Neuroses  of  the  testicle,  163 
Nocturnal  emissions,  168 

o. 

Oligospermia,  167 
Ophthalmia,  gonorrhceal,  54-56 
Orchitis,  154 

symptoms,  155 

treatment,  155 
Oxaluria,  144 

P. 

Paraphimosis,  82 

treatment,  83 
Pediculosis  pubis,  85 

treatment,  86 
Penis,  diseases  of,  79 
epithelioma  of,  79 
diagnosis,  80 
Perineum,  anatomy  of,  127-129 
Phimosis,  82 


INDEX. 


177 


Phosphaturia,  145 
Polyspermia,  167 
Posthitis,  81 

treatment,  81 
Prostate  gland,  86 
anatomy,  86 
calculi,  100 

treatment,  101 
cancer  of,  99 

symptoms,  100 
concretions,  100 
hypertrophy,  86 
neuralgia  of,  102 
treatment,  103 
syphilis  of,  99 
Prostatic  "  bar,"  87 
Prostatitis,  95 
abscess,  97 

treatment,  97 
follicular,  98 

treatment,  98 
symptoms,  96 
treatment,  96 
Psvchrophor,  166,  167 
Pyelitis,  134-136 
Pyonephrosis,  134-136 

K. 

Renal  calculus,  132 

symptoms,  132 

treatment,  134 
colic,  133 

treatment,  134 
Residual  urine,  89 
Retention  of  urine,  73,  75,  92 
Rheumatism,  gonorrhceal,  51 
Rupture  of  bladder,  74,  106 

S. 

Salivation,  29 

Semen,  anomalies  of,  167 

Sore  throat,  25 

Spermatic  cord,  hydrocele  of,  153,  154 

symptoms,  154 
Spermatocele,  153 
Spermatorrhoea,  169 

treatment,  170 
Sterility,  168 
Stricture,  56 

causes,  58 

complications,  74 

examination  of,  58 

12— G.  U. 


Stricture,  examination  of,  dangers,  59 
precautions,  60 

organic,  57 

pathology,  58 

seats,  58 

symptoms,  61 

treatment,  62 

of  the  urethra,  56 
Surgical  kidney,  137 

treatment,  138 
Syphilides,  22 

characteristics,  23 
Syphilis,  18 

cachexia  of,  22 

definition,  18 

diagnosis,  22 

infantile,  30 

inherited,  30 

of  the  kidney,  142 

late  lesions  of,  25 

"  stages  "  of,  22 

treatment,  26 
Syphilitic  bubo,  21 

disease  of  testicle,  160 
treatment,  161 

iritis,  23 

lymphangitis,  21 

T. 

Testicle,  anatomy  of,  146,  147 
anomalies  of,  147 
atrophy,  148 
diseases  of,  146 
displacement,  148 
formation  of,  147 
neuroses  of,  163 
retention  of,  148 
syphilis  of,  160 
tuberculosis  of,  159 
tumors  of,  162 
Tubercular  prostatitis,  99 

symptoms,  99 
Tuberculosis  of  the  kidney,  138 
symptoms,  139 
treatment,  139 
Tuberculous  disease  of  testicle,  159 

treatment,  160 
Tumors  of  the  kidney.  139 
benign,  139 
malignant,  140 
of  the  testicle,  162 
cystic,  162 
solid,  162 


178 


INDEX. 


u. 

Ureters,  diseases  of,  130,  131 
Urethra,  37 

anatomy  of,  37,  38 
Urethral  chill,  60 
treatment,  60,  61 
fever,  60 
Urethritis,  39 
non-specific,  39 
specific,  40 
Urethrometry,  63 
Urethrotomy,  62 
external,  68 
internal,  64 
kinds  of,  62 
Uric-acid  diathesis,  146 
Urinary  overflow,  89 
calculus,  115 
chemical  examination  of,  117 
formation,  116 
operations  for,  119 
physical  examination,  118 


Urinary  calculus,  shape,  117 

size,  117 

symptoms,  118 
Urine,  abnormalities  of,  144 
incontinence  of,  106 


V. 

Varicocele,  170 
symptoms,  171 
treatment,  171 
operative,  172 
Venereal  diseases,  17 
definition,  17 
warts,  36 
treatment,  37 


w. 

Warts,  venereal,  36 
Washing  out  the  bladder,  93 


LEA  BROTHERS  &  GO'S  LIST 

OF    THE 

Leading  Medical  Text-Books 


O 
U. 

Ul 

C0 


ISI 


o 
I- 


cc 

o 


^natom^,  dictionaries. 


Gray's  Anatomy— 12th  Edition.    Colors  or  Black. 


Anatomy,  Descriptive  and  Surgical.  By  Henky  Gray, 
F.  R.  S.,  Lecturer  on  Anatomy  at  St.  George's  Hospital,  London.  Edited 
by  T.  Pickering  Pick,  F.  R.  C.S.,  Surgeon  to  and  Lecturer  on  Anatomy 
<  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy,  Eoyal  College  of 
Surgeons  of  England.  A  new  American  from  the  eleventh  enlarged  and 
Uj  improved  London  edition,  thoroughly  revised  and  re-edited  by  William 
CO  W.  Keen,  M.  D.  ,  Professor  of  Surgery  in  the  Jefferson  Medical  College  of 
^  Philadelphia.  To  which  is  added  the  second  American  from  the  latest 
uj  English  edition  of  Landmarks,  Medical  and  Surgical,  by  Luther 
cc  HoLDEN,  F.  E.  C.  S.  In  one  imperial  octavo  volume  of  1098  pages,  with 
^  685  large  and  elaborate  engravings  on  wood.  Price  of  edition  in  black  : 
Cloth,  $6.00  ;  leather,  $7.00  ;  half  Russia,  $7.50.  Price  of  edition  in  colors : 
Cloth,  $7.25  ;  leather,  $8.25  ;  half  Russia,  $8.75. 


CJ  The  most  popular  work  on  anatomy  ever 

^  written.    It  is  sufficient  to  say  of  it  that  this 

CO  edition,  thanks  to  its  American  editor,  sur- 

h"  passes  all  other  editions . — Journal  of  the  Amer- 

Z  ican  Medical  Association,  December  31, 1887. 

^  Gray's  Anatomy  is  the  most  magnificent 

^  work  upon  anatomy  which  has  ever  been  pub- 

^  lished  in  the  English  or  any  other  language. 

{/5  — Cincinnati  Medical  News,  Nov.  1887. 


As  the  book  now  goes  to  the  purchaser  he  is 
receiving  the  best  work  on  anatomy  that  is 
published  in  any  language. —  Virginia  Medi- 
cal Monthly,  December,  1887. 

Gray's  standard  Anatomy  has  been  and  will 
be  for  years  the  text-book  for  students.  The 
book  needs  only  to  be  examined  to  be  per- 
fectly understood. — Medical  Press  of  Western 
New  York,  January,  1888. 


Dunglison's  Medical  Dictionary. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical 
Science :  Containing  a  concise  Explanation  of  the  various  Subjects  and 
Terms  of  Anatomy,  Physiology,  Pathology,  Hygiene,  Therapeutics,  Phar- 
macology, Pharmacy,  Surgery,  Obstetrics,  Medical  Jurisprudence  and 
Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formulae  for  Officinal, 
Empirical  and  Dietetic  Preparations.  With  the  Accentuation  and  Ety- 
mology of  the  Terms,  and  the  French  and  other  Synonymes,  so  as  to 
constitute  a  French  as  well  as  an  English  Medical  Lexicon.  By  Robley 
DuNGLisoN,  M.  D.,  Late  Professor  of  Institutes  of  Medicine  in  the  Jeffer- 
son Medical  College  of  Philadelphia.  Edited  by  Richard  J.  Dunglison, 
M.  D.  In  one  very  large  and  handsome  royal  octavo  volume  of  1139  pages. 
Cloth,  $6.50;  leather,  raised  bands,  $7.50;  very  handsome  half  Russia, 
raised  bands,  $8.00. 


'    Hoblyn's  Medical  Dictionary. 

A  Dictionary  of  the  Terms  Used  in  Medicine  and 
the  Collateral  Sciences.  BjEichaed  D.  Hoblyn,  M.  D.  Eevised, 
with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of  The  Amer- 
ican Journal  of  the  Medical  Sciences.  In  one  large  royal  12mo.  volume  of 
520  double-columned  pages.     Cloth,  $1.50  ;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  be  upon  the  student's  table. 
— Southern  Medical  and  Surgical  Journal. 


Foster's  Physiology— New  (Fifth)  Edition. 

Text-Book  of  Physiology.  By  Michael  Fostee,  M.  D., 
F.  E.  S.,  Prelector  in  Physiology  and  Fellow  of  Trinity  College,  Cambridge, 
England.  New  (fifth)  and  enlarged  American  from  the  fifth  and  revised 
English  edition,  with  notes  and  additions.  In  one  handsome  octavo  vol- 
ume of  1072  pages,  with  282  illustrations.     Cloth,  $4.50  ;  leather,  $5.50. 

editions  has  been  by  the  author  largely 
adopted  in  a  modified  form  in  this  revision, 
much  was  still  left  to  be  done  by  the  editor 


The  appearance  of  another  edition  of 
Foster's  Physiology  again  reminds  us  of  the 
continued  popularity  of  this  most  excellent 
work.  There  can  be  no  doubt  that  this  text- 
book not  only  continues  to  lead  all  others  in 
the  English  language,  but  that  this  last  edi- 
tion is  superior  to  its  predecessors.  It  is 
evident  that  the  author  has  devoted  a  con- 
siderable amount  of  time  and  labor  to  its 
preparation,  nearly  every  page  bearing  evi- 
dences of  careful  revision.  Although  the 
work  of  the  American   editor  in   former 


to  render  the  work  fully  adapted  to  the 
wants  of  our  American  students,  so  that  the 
American  edition  will  undoubtedly  continue 
to  supply  the  market  on  this  side  of  the 
Atlantic.  The  work  has  been  published  in  the 
characteristic  creditable  style  of  the  Lea's, 
and  owing  to  its  enormous  sale  is  offered  at 
an  extremely  low  price. — The  Medical  and 
Surgical  Reporter,  January  9, 1892. 


Chapman's  Physiology. 

A  Treatise  on  Human  Physiology.  By  Heney  C. 
Chapman,  M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical  Juris- 
prudence in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  hand- 
some octavo  volume  of  925  pages,  with  605  fine  engravings.  Cloth,  $5.50  ; 
leather,  $6.50. 

Dalton's  Physiology— Seventh  Edition. 

A  Treatise  on  Human  Physiology.  Designed  for  the 
use  of  Students  and  Practitioners  of  Medicine.  By  John  C.  Dalton, 
M.  D.,  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons, 
New  York,  etc.  Seventh  edition,  thoroughly  revised  and  rewritten.  In 
one  very  handsome  octavo  volume  of  722  pages,  with  252  beautiful  engrav- 
ings on  wood.     Cloth,  $5.00  ;  leather,  $6.00. 

is  quoted  by  other  writers  on  physiology. 
This  fact  attests  its  value,  and,  in  great 
measure,  its  originality.     It  now  needs  no 


From  the  first  appearance  of  the  book  it 
has  been  a  favorite,  owing  as  well  to  the 
author's  renown  as  an  oral  teacher  as  to  the 
•charm  of  simplicity  with  which,  as  a  writer, 
he  always  succeeds  in  investing  even  intri- 
cate subjects.  It  must  be  gratifying  to  him 
to  observe  the  frequency  with  which  his 
work,  written  for  students  and  practitioners, 


such  seal  of  approbation,  however,  for  the 
thousands  who  have  studied  it  in  its  various 
editions  have  never  been  in  any  doubt  as  to 
its  sterling  worth. — Ntw  York  Medical  Jour- 
nal, October,  1882. 


J)l)g0ic6,  Cliemistrg. 


Draper's  Medical  Physics. 


Medical  Physics.  A  Text-book  for  Students  and  Practi- 
iioners  of  Medicine.  By  JoHisr  C.  Drapee,  M.  D.,  LL.  D.,  Professor  of 
Ohemistry  in  the  University  of  the  City  of  New  York.  In  one  octavo  vol- 
ume of  734  pages,  -with  376  woodcuts,  mostly  original.     Cloth,  $4.00. 


Simon's  Chemistry— Third  Edition. 


Manual  of  Chemistry.  A  Guide  to  Lectnres  and  Labora- 
tory work  for  Beginners  in  Chemistry.  A  Text-book,  specially  adapted 
for  Students  of  Pharmacy  and  Medicine.  By  W.  Simon,  Ph.  D.,  M.  D., 
Professor  of  Chemistry  and  Toxicology  in  the  College  of  Physicians  and 
Surgeons,  Baltimore,  and  Professor  of  Chemistry  in  the  Maryland  College 
of  Pharmacy.  New  (third)  edition.  In  one  8vo.  volume  of  477  pages, 
with  44  woodcuts  and  7  colored  plates  illustrating  56  of  the  most  impor- 
tant chemical  tests.    Cloth,  $3,25. 


Among  the  many  works  on  chemistry- 
offered  for  the  use  of  the  medical  student, 
there  is  probably,  none  that  outrivals  Dr. 
Simon's  work  in  practical  arrangement  and 
i;horoughness,  A  special  feature  of  the 
book-,  and  one  that  deserves  the  greatest 
praise,  is  the  presence  therein  of  the  beauti- 
ful colored  plates  representing  fifty-six 
chemical  reactions.  To  say  that  they  are 
splendidly  and  artistically  executed  hardly 


does  them  justice.  They  must  convey  to 
the  mind  of  the  student  lasting  impressions 
of  the  color  changes  that  he  has  noted  in  his 
experiments  in  the  laboratory,  and  the 
perusal  of  this  work  must  recall  them 
vividly  to  recognition.  The  many  cuts  are 
well  selected,  and  the  make-up  of  the  book 
leaves  nothing  to  be  desired.  As  a  student's 
manual  this  work  is  of  the  highest  order. — 
The  Medical  News,  February  20, 1892. 


Fownes'  Chemistry— Twelfth  Edition. 

A  Manual  of  Elementary  Chemistry ;  Theoretical  and 
Practical.  Embodying  Watts'  Physical  and  Inorganic  Chemistry.  By 
Oeoege  Fownes,  Ph.  D.  New  American,  from  the  twelfth  English  edi- 
tion. In  one  large  royal  12mo.  volume  of  1061  pages,  with  168  illustra- 
tions  on  wood  and  a  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 


Attfield's  Chemistry— Twelfth  Edition. 

Chemistry,  General,  Medical  and  Pharmaceutical; 

Including  the  Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the 
General  Principles  of  the  Science,  and  their  Application  to  Medicine  and 
Pharmacy.  By  John  Attfield,  M.  A.,  Ph.D.,  F.  LC,  F.  E.  S.,  Etc., 
Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great 
Britain,  etc.  A  new  American,  from  the  twelfth  English  edition,  specially 
revised  by  the  Author  for  America.  In  one  handsome  royal  12mo.  vol- 
ume of  782  pages,  with  88  illustrations.    Cloth,  $2.75 ;  leather,  $3.25. 


(ti)em\Btv^,  pi)armar2,  ©berapeutics,  iHcteria  iHeSica. 

Bloxam's  Chemistry— Fifth  Edition. 

Chemistry,  Inorganic  and  Organic.  By  Chaeles  L. 
Bloxam,  Prof,  of  Chemistry  in  King's  College,  London.  New  American 
from  the  fifth  London  edition,  thoroughly  revised  and  much  improved.  In 
one  very  handsome  octavo  vol.  of  727  pages,  with  292  illus.  Cloth,  |2.00  ; 
leather,  $3.00. 

Remsen's  Theoretical  Chemistry— New  (4th)  Ed. 

Principles  of  Theoretical  Chemistry,  with  special  ref- 
erence to  the  Constitution  of  Chemical  Compounds.  By  Iea  Eemsen, 
M.  D.,  Ph.  D.,  Professor  of  Chemistry  in  the  Johns  Hopkins  University, 
Baltimore.  Fourth  and  thoroughly  revised  edition.  In  one  handsome 
royal  12mo.  volume  of  325  pages.     Cloth,  $2.00.     Just  ready. 


Parrish's  Pharmacy— Fifth  Edition. 


A  Treatise  on  Pharmacy :  Designed  as  a  Text-book  for 
the  Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With 
many  Formulae  and  Prescriptions.  By  Edwaed  Paeeish,  late  Professor 
of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of 
Pharmacy.  Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegand, 
Ph.  G.  In  one  handsome  octavo  volume  of  1093  pages,  with  256  illustra- 
tions.    Cloth,  $5.00  ;  leather,  $6.00. 


Stille  &  Maisch's  National  Dispensatory— 4th  Ed. 

The  National  Dispensatory.  Containing  the  Natural 
History,  Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including 
those  recognized  in  the  PharmacopcEias  of  the  United  States,  Great  Britain 
and  Germany,  with  numerous  references  to  the  French  Codex.  By 
Alfeed  Stille,  M.  D.,  LL.  D.,  Professor  Emeritus  of  the  Theory  and 
Practice  of  medicine  and  of  Clinical  Medicine  in  the  University  of  Penn- 
sylvania, and  John  M.  Maisch,  Phae.  D.,  Professor  of  Materia  Medica 
and  Botany  in  Philadelphia  College  of  Pharmacy,  Secretary  to  the  Amer- 
ican Pharmaceutical  Association.  Fourth  edition  revised,  and  covering 
the  new  British  Pharmacopoeia.  In  one  magnificent  imperial  octavo  vol- 
ume of  1794  pages,  with  311  elaborate  engravings.  Price  in  cloth,  $7.25  ; 
leather,  raised  bands,  $8.00;  half  Eussia,  $9.00.  ^^^  This  work  will  be 
furnished  with  Patent  Beady  Reference  Thumb-letter  Index  for  $1.00  in  addi- 
tion to  the  price  in  any  of  the  above  styles  of  binding. 


We  thinK.  it  a  matter  for  congratulation 
that  the  profession  of  medicine  and  that  of 
pharmacy  have  shown  such  appreciation 
of  this  great  work  as  to  call  for  four  editions 
within  the  comparatively  brief  period  of 
eight  years.  The  matters  with  which  it 
deals  are  of  so  practical  a  nature  that 


neither  the  physician  nor  the  pharmacist 
can  do  without  the  latest  text-books  on 
them,  especially  those  that  are  so  accurate 
and  comprehensive  as  this  one.  The  book 
is  in  every  way  creditable  both  to  the  au- 
thors and  to  the  publishers. — New  York  Med- 
ical Journal,  May  21, 1887. 


@^l)erapeutic0,  illateria  iHebica.         ^ 


Maisch's  Materia  Medica— New  (5th)  Ed.  Just  Ready. 

A  Manual  of  Organic  Materia  Medica ;  Being  a  Guide 
to  Materia  Medica  of  the  Vegetable  and  Animal  Kingdoms.  For  tlie  nse 
of  Students,  Druggists,  Pharmacists  and  Physicians.  By  John  M. 
Maisch,  Phar.  D.,  Professor  of  Materia  Medica  and  Botany  in  the  Phil- 
adelphia College  or  Pharmacy.  New  (fifth)  edition,  thoroughly  revised. 
In  one  very  handsome  12mo.  volume  or  544  pages,  witk  270  engravings. 
Cloth,  13.00.    Just  ready. 


Hare's  Practical  Therapeutics— Second  Edition. 

A  Text-Book  of  Practical  Therapeutics;  With 
Especial  Reference  to  the  Application  of  Remedial  Measures  to  Disease 
and  their  Employment  upon  a  Rational  Basis.  By  Hobaet  Amoey 
Haee,  B.  So.,  M.  D.,  Professor  of  Materia  Medica  and  Therapeutics  in 
the  Jefferson  Medical  College  of  Philadelphia  ;  Secretary  of  the  Conven- 
tion for  the  Revision  of  the  United  States  Pharmacopoeia  of  1890.  With 
special  chapters  by  Des.  G.  E.  de  Schwei]!^itz,  Edw'aed  Maetin,  J. 
HowAED  Reeves  and  Baeton  C.  Hiest.  New  (2d)  and  revised  edition. 
In  one  handsome  octavo  vol.  of  650  pages.     Cloth,  $3.75 ;  leather,  $4.75. 


This  work  has  received  the  rare  distinc- 
tion among  medical  works  of  reaching  a 
second  edition  six  months  after  its  first  ap- 
pearance. Many  new  prescriptions  have 
also  been  inserted  to  illustrate  the  best 
modes  of  applying  remedies.  Among  other 
features  of  this  practically  helpful  treatise 
which  will  make  reference  to  it  convenient 
and  profitable,  are  the  arrangement  of  titles 


of  drugs  and  diseases  in  alphabetical  order, 
according  to  their  English  names;  and  a 
dose  list  of  drugs  officinal  and  unofficinal. 
In  addition  to  the  general  index,  a  copious 
and  explanatory  index  of  diseases  and  rem« 
edies  has  been  appended  which  will  render 
the  contents  easily  accessible.— TAc  Medical 
Age,  July  10,  1891. 


Brunton's  Therapeutics  and  Mat.  Med.— 3d  Ed. 

A  Text-Book  of  Pharmacology,  Therapeutics  and 
Materia  Medica ;  Including  the  Pharmacy,  the  Physiological  Action 
and  Therapeutical  Uses  of  Drugs.  By  T.  Laudee  Beunton,  M.  D., 
D.  Sc,  F.  R.  S.,  F.  R.  C.  P.,  Lecturer  on  Materia  Medica  and  Therapeutics 
at  St.  Bartholomew's  Hospital,  London,  etc.  Adapted  to  the  U.  S.  Phar- 
macopoeia by  Feaistcis  H.  Williams,  M.  D  ,  of  Harvard  University 
Medical  School.  Third  edition.  Octavo,  1305  pages,  230  illustrations. 
Cloth,  $5.50  ;  leather,  $6.50. 


No  words  of  praise  are  needed  for  this  work, 
for  it  has  already  spoken  for  itself  in  former 
editions.  It  was  by  unanimous  consent 
placed  among  tue  foremost  books  on  the  sub- 
ject ever  published  in  any  language,  and 
the  better  it  is  known  and  studied  the  more 
highly  it  is  appreciated.  The  present  edition 
contains  much  new  matter,  the  insertion  of 
which  has  been  necesaitated  by  the  advances 


made  in  various  directions  in  the  art  of 
therapeutics,  and  it  now  stands  unrivalled 
in  its  thoroughly  scientific  presentation  of 
the  modes  of  drug  action.  No  one  who 
wishes  to  be  fully  up  to  the  times  in  this 
science  can  afiford  to  neglect  the  study  of  Dr. 
Brunton's  work.  The  indexes  are  excellent, 
and  add  not  a  little  to  the  practical  value  of 
the  ])ook.— Medical  Record,  May  25, 1889. 


l^vactice  of  MXchitinc, 


Lyman's  Practice— Just  Ready. 

The  Principles  and  Practice  of  Medicine.    For  the 

Use  of  Medical  Students  and  Practitioners.  By  Henky  M.  Lyman,  M.  D  , 
Professor  of  the  Principles  and  Practice  of  Medicine,  Ensh  Medical  Col- 
lege, Chicago.  In  one  very  handsome  octavo  volume  of  925  pages,  with 
170  illustrations.     Cloth,  $4.75;  sheep,  $5.75.    Just  ready. 

The  author  has  undertaken  to  present  in  this  volume  not  only  the 
results  of  his  long  experience  as  a  practitioner  and  teacher,  but  to  make  it 
representative  of  the  latest  state  of  knowledge  in  its  department.  The 
work  is  assured  of  wide  use  as  an  unsurpassed  guide  for  the  student  and 
likewise  for  the  practitioner. 

Flint's  Practice— Sixth  Edition. 

A  Treatise  on  the  Principles  and  Practice  of  Med- 
icine. Designed  for  the  use  of  Students  and  Practitioners  of  Medicine. 
By  Austin  Flint,  M.  D.,  LL.  D.,  Professor  of  the  Principles  and  Prac- 
tice of  Medicine  and  of  Clinical  Medicine  in  Bellevue  Hospital  Medical 
College,  New  York.  Sixth  edition,  thoroughly  revised  and  rewritten 
by  the  Author,  assisted  by  William  H.  Welch,  M.  D.,  Professor 
of  Pathology,  Johns  Hopkins  University,  Baltimore,  and  Austin  Flint,^ 
Jr.,  M.  D.,  LL.  D.,  Professor  of  Physiology,  Bellevue  Hospital  Medical 
College,  New  York.  In  one  very  handsome  octavo  volume  of  1160  pages, 
with  illustrations.     Cloth,  $5.50;  leather,  $6.50. 

town,  village,  or  at  some  cross-roads,  is 
Flint's  Practice.  We  make  this  statement  ta 
a  considerable  extent  from  personal  observa- 


No  text-book  on  the  principles  and  prac- 
tice of  medicine  has  ever  met  in  this  country 
with  such  general  approval  by  medical  stu- 
dents and  practitioners  as  the  work  of  Pro- 
fessor Flint.  In  all  the  medical  colleges  of 
the  United  States  it  is  the  favorite  work 
upon  Practice;  and,  as  we  have  stated  be- 
fore in  alluding  to  it,  there  is  no  other  medi- 
cal work  that  can  be  so  generally  found  in 
the  libraries  of  physicians.  In  every  state 
and  territory  of  this  vast  country  the  book 
that  will  be  most  likely  to  be  found  in  the 
office  of  a  medical  man,  whether  in  city, 


tion,  and  it  is  the  testimony  also  of  others. 
An  examination  shows  that  very  considera- 
ble changes  have  been  made  in  the  sixth 
edition.  The  work  may  undoubtedly  be  re- 
garded as  fairly  representing  the  present 
state  of  the  science  of  medicine,  and  as 
reflecting  the  views  of  those  who  exemplify 
in  their  practice  the  present  stage  of  pro- 
gress of  medical  art. — Cincinnati  Medical 
News,  Oct.  1886. 


Hartshorne's  Essentials—Fifth  Edition. 

Essentials  of  the  Principles  and  Practice  of  Medi- 
cine. A  Handbook  for  Students  and  Practitioners.  By  Heney  Haets- 
HOENE,  M.  D. ,  LL.  D. ,  lately  Professor  of  Hygiene  in  the  University  of 
Pennsylvania.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.  Cloth,  $2.75j 
half  bound,  $3.00. 


An  indispensable  book.  No  wort  ever 
exhibited  a  better  average  of  actual  practical 
treatment  than  this  one ;  and  probably  not 
one  writer  in  our  day  had  a  better  opportu- 
nity than  Dr.  Hartshorne  for  condensing  all 
the  views  of  eminent  practitioners  into  a 
12mo.    The  numerous  illustrations  will  be 


very  useful  to  students  especially.  These 
essentials  are  most  valuable  in  affording  the 
means  to  see  at  a  glance  the  whole  literature 
of  any  disease,  and  the  most  valuable  treat- 
ment.—CA^'cag'O  Medical  Journal  and  Ex- 
aminer,  April,  1882. 


Jpraaice  of  Mchicinc,  ^istolog^i  P^tliologg. 


FothergiU's  Handbook  of  Treatment— 3d  Edition. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  the 

Principles  of  Therapeutics.  By  J.  M.  Fotheegill,  M.D.,  Edin.,  M.R.C.P., 
LoND.,  Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest, 
Third  edition.  In  one  8vo.  vol.  of  661  pages.  Cloth,  $3.75  ;  leather,  $4.75. 


Flint's  Auscultation  and  Percussion— Fifth  Edition. 

A  Manual   of  Auscultation  and  Percussion ;    Of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic 
Aneurism.  By  Austin  Flint,  M.  D.,  LL.  D.,  Professor  of  the  Principles 
and  Practice  of  Medicine  in  Bellevue  Hospital  Medical  College,  N.  Y.  Fifth 
edition.  Edited  by  James  C.  Wilson,  M.  D.,  Lecturer  on  Physical  Diag- 
nosis ia  the  Jefferson  Medical  College,  Philadelphia.  In  one  handsome 
royal  12mo.  volume  of  274  pages,  with  12  illustrations.    Cloth,  $1.75. 

This  little  book  through  its  various  edi- 
tions has  probably  done  more  to  advance  the 
science  of  physical  exploration  of  the  chest 


than  any  other  dissertation  upon  the  sub- 
ject, and  now  in  its  fifth  edition  it  is  as  near 
perfect  as  it  can  be.  The  rapidity  with 
which  previous  editions  were  sold  shows 
how  the  profession  appreciates  the  thorough- 


ness of  Prof.  Flint's  investigations.  For 
students  it  is  excellent.  Its  value  is  shown 
both  in  the  arrangement  of  the  material  and 
in  the  clear,  concise  style  of  expression. 
For  the  practitioner  it  is  a  ready  manual  for 
Teievence.— North  American  Practitioner,  Jan- 
uary, 1891. 


Gibbes'  Histology  and  Pathology. 


Practical   Pathology   and    Morbid   Histology.     By 

Heneage  Gibbes,  M.  D.,  Professor  of  Pathology  in  the  University  of 
Michigan,  Medical  Department.  In  one  very  handsome  octavo  volume  of 
314  pages,  with  60  illustrations,  mostly  photographic.    Cloth,  $2.75. 


This  is,  in  part,  an  expansion  of  the  little 
work  published  by  the  author  some  years 
ago,  and  his  acknowledged  skill  as  a  practi- 
cal microscopist  will  give  weight  to  his  in- 
structions. Indeed,  in  fulness  of  directions 
as  to  the  modes  of  investigating  morbid  tis- 


sues the  book  leaves  little  to  be  desired.  The 
work  is  throughout  profusely  illustrated 
with  reproductions  of  micro-photographs. 
We  may  say  that  the  practical  histologist 
will  gain  much  useful  information  from  tlie 
hook.— The  London  Lancet,  January  23, 1892. 


Green's  Pathology  and  Morbid  Anatomy— 7tli  Ed. 

Pathology  and  Morbid  Anatomy.  By  T.  Heney  Geeen, 
M.  D.,  Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Cross  Hos- 
pital Medical  School,  London.  Sixth  American  from  the  seventh  revised 
English  edition.    Octavo,  539  pages,  with  167  engravings.     Cloth,  $2.75. 

It  la  better  adapted  to  the  wants  of  gen- 
eral practitioners  than  any  work  of  the  kind 
with   which  we  are  acquainted.    The  cuts 


exhibit   the    appearances    of    pathological 
fltructures  just  as  they  are  seen  through  the 


microscope.  The  fact  thet  it  is  so  generally 
employed  as  a  text-book  by  medical  students 
is  evidence  that  we  have  not  spoken  toomuch 
in  its  favor.— Cincinnati  Medical  News,  Octo- 
ber, 1889. 


J)atl/oio92»  ^istolo^a*  3attcxioio%^, 

Payne's  General  Pathology. 

A  Manual  of  General  Pathology.  Designed  as  an  Intro- 
duction to  the  Practice  of  Medicine.  By  Joseph  F.  Payne,  M.  D., 
F.  R.  C.  P.,  Senior  Assistant  Physician  and  Lecturer  on  Pathological 
Anatomy,  St.  Thomas'  Hospital,  London.  Octavo  of  524  pages,  with  152 
illustrations  and  a  colored  plate.    Cloth,  $3.50. 


Knowing,  as  a  teacher  and  examiner,  the 
exact  needs  of  medical  students,  the  author 
has  in  the  work  before  us  prepared  for  their 
especial  use  what  we  do  not  hesitate  to  say 
is  the  best  introduction  to  general  pathology 
that  we  have  yet  examined.  A  departure 
which  our  author  has  taken  is  the  greater 
attention  paid  to  the  causation  of  disease, 
and  more  especially  to  the  etiological  factors 


in  those  diseases  now  with  reasonable  cer- 
tainty ascribed  to  pathogenetic  microbes. 
In  this  department  he  has  been  very  full 
and  explicit,  not  only  in  a  descriptive  man- 
ner, but  in  the  technique  of  investigation. 
The  Appendix,  giving  methods  of  research, 
is  alone  worth  the  price  of  the  book,  several 
times  over,  to  every  student  of  pathology. — 
Si.  Louis  Med.  and  Surgical  Jour.,  Jan.  1889. 


Klein's  Histology— Fourth  Edition. 

Elements  of  Histology.  By  E.  Klein,  M.  D.,  F.  R.  S., 
Joint  Lecturer  on  General  Anatomy  and  Physiology  in  the  Medical  School 
of  St.  Bartholomew's  Hospital,  London.  Fourth  edition.  In  one  12mo. 
volume  of  376  pages,  with  194  illustrations.  Limp  cloth,  $1.75.  See  Stu- 
dents^ Series  of  Manuals,  page  30. 


Abbott's  Bacteriology. 

The  Principles  of  Bacteriology :  a  Practical  Manual  for 
Students  and  Physicians.  By  A.  C.  Abbott,  M.  D.,  First  Assistant,  Lab- 
oratory of  Hygiene,  University  of  Pennsylvania,  Philadelphia.  In  one 
12mo.  volume  of  259  pages,  with  32  illustrations.   Cloth,  $2.00.  Just  ready. 

furnishes  an  excellent  guide  to  the  student. 
Of  equal  importance  is  the  chapter  on  disin- 


On  reading  this  manual  of  Dr.  Abbott,  any 
one  familiar  with  the  subject  will  readily 
recognize  the  fact  that  the  book  is  not 
merely  a  compilation  from  other  works,  but 
one  giving  evidence  of  the  originality  of  the 
author,  as  well  as  complete  knowledge  of 
the  practical  details  of  bacteriology.  His 
"  scheme  for  the  study   of  an   organism" 


fectants,  antiseptics  and  skin  disinfection. 
It  will  form  a  valuable  addition  to  the  litera- 
ture of  laboratory  technique  and  bacterio- 
logical investigation, — The  Therapeutic  Ga- 
zette, May  16, 1892. 


Senn's  Surgical  Bacteriology— Second  Edition. 

Surgical  Bacteriology.  By  Nicholas  Senn,  M.  D., 
Ph.  D.,  Professor  of  Surgery  in  Rush  Medical  College,  Chicago.  New 
(second)  edition.  In  one  handsome  octavo  of  268  pages,  with  13  plates,  of 
which  10  are  colored,  and  9  engravings.     Cloth,  $2.00. 


Coats'  Pathology. 

A  Treatise  on  Pathology.  By  Joseph  Coats,  M.  D., 
F.  F.  P.  S.,  Pathologist  to  the  Glasgow  Western  Infirmary.  In  one  very 
handsome  octavo  volume  of  829  pages,  with  339  beautiful  illustrations. 
Cloth,  15.50;  leather,  |6. 50. 


Gray  on  Nervous  and  Mental  Diseases. 

A  Practical  Treatise  on  Nervous  and  Mental  Dis- 
eases. By  Landon  Caeter  Geay,  M.  D.,  Professor  of  Diseases  of  the 
Mind  and  Nervous  System  in  the  New  York  Polyclinic.  Shortly. 
nnHIS  work  is  devoted  purely  to  the  practical  aspects  of  nervous  and  mental 
-*-  diseases,  especial  care  being  taken  to  present  the  fundamental  knowledge 
essential  to  a  grasp  of  its  subjects  and  to  cast  everything  in  the  clearest  possible 
form.  The  series  of  illustrations  are  rich  and  unique,  embracing  a  large  num- 
ber of  photographic  engravings  of  exceptional  vividness  and  interest.  By  the 
employment  of  a  style  at  once  concise  and  clear,  and  by  careful  arrangement, 
the  author  is  enabled  to  include  an  exposition  of  a  vast  and  important  subject 
in  a  condensed  and  convenient  form.  It  will  be  an  admirable  work  for  the 
student  as  well  as  for  the  practitioner. 


Ross  on  Nervous  Diseases. 

A  Handbook  on  Diseases  of  the  Nervous  System. 
By  James  Eoss,  M.  D.,  F.  E.  C.  P.,  LL.  D.,  Senior  Assistant  Physician  to 
the  Manchester  Eoyal  Infirmary.  In  one  octavo  volume  of  725  pages,  with 
184  illustrations.     Cloth,  $4.50  ;  leather,  $5.50. 


This  admirable  work  is  intended  for 
students  of  medicine  and  for  such  medical 
men  as  have  no  time  for  lengthy  treatises. 
In   every   part  this  handbook  merits  the 


highest  praise,  and  will  no  doubt  be  found 
of  the  greatest  value  to  the  student  as  well 
as  to  the  practitioner. — Edinburgh  Medical 
Journal,  Jan.  1887. 


Roberts'  Modern  Surgery. 

The  Principles  and  Practice  of  Modern  Surgery. 
For  the  use  of  Students  and  Practitioners  of  Medicine  and  Surgery.  By 
John  B.  Eobeets,  M.  D.,  Professor  of  Anatomy  and  Surgery  in  the  Phila- 
delphia Polyclinic ;  Professor  of  the  Principles  and  Practice  of  Surgery  in 
the  Woman's  Medical  College  of  Pennsylvania;  Lecturer  in  Anatomy  in 
the  University  of  Pennsylvania.  In  one  very  handsome  octavo  volume  of 
780  pages,  with  501  illustrations.     Cloth,  $4.50 ;  leather,  $5.5^^. 


This  work  is  a  very  comprehensive  man- 
ual upon  general  surgery,  and  will  doubtless 
meet  with  a  favorable  reception  by  the  pro- 
fession. It  has  a  thoroughly  practical  charac- 
ter, the  subjects  are  treated  with  rare  judg- 
ment, its  conclusions  are  in  accord  with 
those  of  the  leading  practitioners  of  the  art, 
and  its  literature  is  fully  up  to  all  the  ad- 


vanced doctrines  and  methods  of  practice  of 
the  present  day.  Its  general  arrangement 
follows  this  rule,  and  the  author  in  his  desire 
to  be  concise  and  practical  is  at  times  almost 
dogmatic,  but  this  is  entirely  excusable  con- 
sidering the  admirable  manner  in  which  he 
has  thus  increased  the  usefulness  of  hia 
yfov):..— Medical  Record,  Jan.  17, 1891. 


ErMsen's  Surgery— Eighth  Edition. 

The  Science  and  Art  of  Surgery;  Being  a  Treatise  on 
Surgical  Injuries,  Diseases  and  Operations.  By  John  E.  Erichsen,  F.E.S.  , 
F.  E.  C.  S.,  Professor  of  Surgery  in  University  College,  London,  etc.  From 
the  eighth  and  enlarged  English  edition.  In  two  large  8vo,  volumes  of  2316 
pages,  with  984  engravings  on  wood.     Cloth,  |9.00  ;  leather,  |11.00. 


Surgery* 

Ashhurst's  Surgery— Fifth  Edition. 

The  Principles  and  Practice  of  Surgery.  By  John 
AsHHUEST,  Jr.,  M.  D.,  Barton  Professor  of  Surgery  and  Clinical  Surgery 
in  the  University  of  Penn'a ;  Surgeon  to  the  Penn'a  Hospital,  Phila.  Fifth 
edition,  enlarged  and  thoroughly  revised.  In  one  large  and  handsome 
octavo  volume  of  1144  pages,  with  642  illos.    Cloth,  $6.00 ;  leather,  $7.00. 


A  complete  and  most  excellent  work  on 
surgery.  It  is  only  necessary  to  examine  it 
to  see  at  once  its  excellence  and  real  merit 
either  as  text-book  for  the  student  or  a 
guide  for  the  general  practitioner.  It  fully 
considers  in  detail  every  surgical  injury 
and  disease  to  which  the  body  is  liable,  and 


every  advance  in  surgery  worth  noting  is 
to  be  found  in  its  proper  place.  It  is  un- 
questionably the  best  and  most  complete 
single  volume  on  surgery,  in  the  English 
language,  and  cannot  but  receive  that  con- 
tinued appreciation  which  its  merits  justly 
demand.— Southern  Practitioner^  Feb.  1890. 


Druitt's  Modern  Surgery. 

Manual  of  Modern  Surgery.  By  Eobeet  Deuitt, 
M.  E.  C.  S.,  etc.  Twelfth  edition,  thoroughly  revised  by  Stanley  Boyd, 
M.  B.,  B.  S.,  F.  R.  C.  S.  In  one  8vo.  volume  of  965  pages,  with  373  illus- 
trations.    Cloth,  $4.00 ;  leather,  $5.00. 

Bryant's  Surgery— Fourth  Edition. 

The  Practice  of  Surgery.  By  Thomas  Beyant,  F.R.C.S., 
Surgeon  and  Lecturer  on  Surgery  at  Guy's  Hospital,  London.  Fourth 
American  from  the  fourth  and  revised  English  edition.  In  one  large  and 
very  handsome  imperial  octavo  volume  of  1040  pages,  with  727  illustra- 
tions.    Cloth,  $6.50  ;  leather,  $7.50. 

Wharton's  Minor  Surgery  and  Bandaging. 

Minor  Surgery  and  Bandaging.  By  Heney  E.  Whae- 
TON,  M.D.,  Demonstrator  of  Surgery  and  Lecturer  on  Surgical  Diseases  of 
Children  in  the  University  of  Penna.  In  one  very  handsome  12mo.  volume 
of  498  pp.,  with  403  engravings,  many  being  photographic.     Cloth,  $3.00. 


This  new  work  must  take  a  first  rank  as 
soon  as  examined.  Bandaging  is  well  de- 
scribed by  words,  and  the  methods  are  illus- 
trated by  photographic  drawing?,  so  to  make 
plain  each  step  taken  in  the  application  of 
bandages  of  various  kinds  to  different  parts 
of  the  body  and  extremities— including  the 
head.  The  various  operations  are  likewise 
described  and  illustrated,  so  that  it  would 
seem  easy  for  the  tyro  to  do  the  gravest 
amputation.    The  various  established  opera- 


tions are  described  in  detail.  Hence  this 
work  becomes  a  most  valuable  companion- 
book  to  any  of  the  more  pretentious  treatises 
on  surgery,  where  simply  the  general  advice 
is  given  to  bandage,  amputate  intubate, 
operate,  etc.  For  the  student  and  young 
surgeon,  it  is  a  very  valuable  instruction 
book  from  which  to  learn  how  to  do  what 
may  be  advised,  in  general  terms,  to  be  done, 
—  Virginia  Medical  Monthly,  October,  1891, 


Holmes'  Treatise  on  Surgery. 

A  Treatise  on  Surgery ;  Its  Principles  and  Practice. 

By  Timothy  Holmes,  M.  A.,  Surgeon  and  Lecturer  on  Surgery  at  St. 
George's  Hospital,  London.  From  the  fifth  English  edition,  edited  by  T. 
Pickering  Pick,  F.  R.  C.  S.  In  one  octavo  volume  of  997  pages,  with  428 
illustrations.     Cloth,  $6.00;  leather,  $7.00. 


0urger2. 


Treves'  Operative  Surgery. 


A  Manual  of  Operative  Surgery.  By  Feedeeick 
Treves,  F.  R.  C.  S.,  Surgeon  and  Lecturer  on  Anatomy  at  the  London 
Hospital.  In  two  octavo  volumes  containing  1550  pages,  with  422  original 
engravings.     Complete  work,  cloth,  |9.00  ;  leather,  §11.00.     Just  ready. 


We  have  no  hesitation  in  declaring  it  the 
best  work  on  the  subject  in  the  English 
language,  and  indeed  in  many  respects 
the  best  in  any  language.  We  feel  called 
upon  to  recommend  the  book  so  strongly  for 
the  excellent  judgment  displayed  in  the 
arduous  task  of  selecting  from  among  the 
thousands  of  yarying  procedures  those  most 


•worthy  of  description ;  for  the  way  in  which 
the  still  more  difficult  task  of  choosing  among 
the  best  of  those  has-been  accomplished ;  and. 
for  the  simple,  clear,  straightforward  manner 
in  which  the  information  thus  gathered 
from  all  surgical  literature  has  been  con- 
veyed to  the  reader,— ^nnaiJs  of  Surgery,. 
March,  1892. 


Smith's  Operative  Surgery. 


The  Principles  and  Practice  of  Operative  Surgery. 

By  Stephen  Smith,  M.  D.,  Professor  of  Clinical  Surgery  in  the  University 
of  the  City  of  New  York.  Second  and  thoroughly  revised  edition.  In  on& 
very  handsome  octavo  volume  of  892  pages,  with  1005  illustrations.  Cloth, 
$4.00;  leather,  $5.00. 

It  can  be  truly  said  that  as  a  handbook  will  its  readers,  no  matter  how  unusual  the 

for  the  student,  a   companion  for  the  sur-  subject,  consult  its  pages  in  vain      Its  com- 

geon,  and  even  as  a  book  of  reference  for  the  pact  form,  excellent  print,  numerous  illustra- 

physician   not    especially    engaged   in    the  tions,  and  especially  its  decidedly  practical 

practice  of  surgery,  this  volume  will  long  character,  all  combine  to  commend  it. — Bos- 

hold  a  most  conspicuous  place,  and  seldom  ton  Medical  and  Surgical  Journal,  May  10,  '8S. 


Hamilton  on  Fractures  and  Dislocations. 

A  Practical  Treatise  on  Fractures  and  Dislocations. 
By  Feank  H.  Hamilton,  M.  D.,  LL.  D.,  Surgeon  to  Bellevue  Hospital, 
New  York.  New  (eighth)  edition,  revised  and  edited  by  Stephen  Smith, 
A.  M.,  M.  D.,  Professor  of  CUnical  Surgery  in  the  University  of  the  City  of 
New  York.  In  one  very  handsome  octavo  volume  of  832  pages,  vdth  507 
illustrations.     Cloth,  $5.50;  leather,  $6.50. 


It  is  pre-eminently  the  authority  on  frac- 
tures and  dislocations,  and  universally 
quoted  as  such.  The  additions  it  has  re- 
ceived by  its  recent  revision  make  it  a  work 
thoroughly  in  accordance  with  modern  prac- 
tice, theoretically,  mechanically,  aseptically. 


The  more  one  reads  the  more  one  is  im- 
pressed with  its  completeness.  The  work 
has  been  accomplished,  and  has  been  done 
clearly,  concisely,  excellently  well. — Boston- 
Medical  and  Surgical  Journal,  May  26, 1892. 


Stimson's  Operative  Surgery. 


A  Manual  of  Operative  Surgery.  By  Lewis  A.  Stimson, 
B.  A.,  M.  D.,  Professor  of  Clinical  Surgery  in  the  Medical  Faculty  of  the 
University  of  the  City  of  New  York.  Second  edition.  In  one  very  hand- 
some royal  12mo.  volume  of  503  pages,  with  342  illustrations.    Cloth,  $2.50» 


Stimson  on  Fractures  and  Dislocations. 

A  Treatise  on  Fractures  and  Dislocations.    In  two 

handsome  octavo  volumes.  Vol.  I.,  Fractuees,  582  pages,  360  beautiful 
illustrations.  Vol.  II.,  Dislocations,  540  pages,  with  163  illustrations. 
Complete  work,  cloth,  |5.50;  leather,  |7.50.  Either  volume  separately, 
cloth,  13.00  ;  leather,  $4.00. 


The  appearance  of  the  second  volume 
marks  the  completion  of  the  author's  origi- 
nal plan  of  preparing  a  work  which  should 
present  in  the  fullest  manner  all  that  is 
known  on  the  cognate  subjects  of  Fractures 


and  Dislocations.  The  volume  on  Fractures 
assumed  at  once  the  position  of  authority  on 
the  subject,  and  its  companion  on  Disloca- 
tions will  no  doubt  be  similarly  received.— 
Cincinnati  Medical  News,  May,  1888. 


Norris  &  Oliver  on  the  Eye— In  Press. 

A  Text-Book  of  Ophthalmology.  By  William  F. 
ITOEEIS,  M.  D.,  Clinical  Professor  of  Ophthalmology  in  University  of 
Penna.,  and  Charles  A.  Oliver,  M.D.  In  one  octavo  volume  of  about 
800  pages,  richly  illustrated  with  engravings  and  colored  plates.     In  press. 

TN  PEEPAEING  this  volume  the  authors  have  had  in  view  the  needs  of 
-^  students,  physicians  and  specialists.  Its  concise  and  clear  style,  its 
completeness  and  the  beautiful  series  of  illustrations  will  at  once  render  it  a 
favorite  work  with  all  classes  for  whom  it  is  intended. 


Nettleship's  Students'  Guide  tc  the  Eye— 5th  Ed. 

Diseases  of  the  Eye.  By  Edward  Nettleship,  F.E.C.S., 
Ophthalmic  Surgeon  at  St.  Thomas'  Hospital,  London.  Surgeon  to  the 
Eoyal  London  (Moorfields)  Ophthalmic  Hospital.  Fourth  American  from 
the  fifth  English  edition,  thoroughly  revised.  "With  a  Supplement  on  the 
Detection  of  Color  Blindness,  by  William  Thomson,  M.  D.,  Professor  of 
Ophthalmology  in  the  Jefferson  Medical  College.  In  one  12mo.  volume 
of  500  pages,  with  164  illustrations,  selections  from  Snellen's  test-types 
and  formulae,  and  a  colored  plate.     Cloth,  $2.00. 


It  was  primarily  intended  for  the  use  of 
students,  and  supplies  their  needs  admir- 
ably, but  it  is  as  useful  for  the  practitioner. 
It  does  not  presuppose  the  large  amount  of 
recondite  knowledge  to  be  present  which 


seems  to  be  assumed  in  some  of  our  larger 
works,  is  not  tedious  from  over-conciseness, 
and  yet  covers  the  more  important  parts  of 
clinical  ophthalmology. — New  York  Medical 
Journal,  December  13, 1890. 


Burnett  on  tbe  Ear. 

The  Ear ;  Its  Anatomy,  Physiology  and  Diseases.  A 
Practical  Treati&e  for  the  use  of  Medical  Students  and  Practitioners.  By 
Chaeles  H.  Buenett,  A.M.,  M.D.,  Professor  of  Otology  in  the  Philadel- 
phia Polyclinic  ;  President  of  the  American  Otological  Society.  Second 
edition.  In  one  handsome  octavo  volume  of  580  pages,  with  107  illustra- 
tions.    Cloth,  $4.00  ;  leather,  $5.00. 

Dr.  Burnett  has  fully  maintained  his  rep- 
■utationjfor  the  book  is  replete  with  valuable 
information  and  suggestions.  The  revision 
has  been  carefully  carried  out,  and  much 
new  matter  added.  Dr.  Burnett's  work 
must  be  regarded  as  a  very  valuable  contri- 


bution to  aural  surgery,  not  only  on  account 
of  its  comprehensiveness,  but  because  it  con- 
tains the  results  of  the  careful  personal 
observation  and  experience  of  this  eminent 
aural  surgeon. — London  Lancet,  Feb.  21, 1885. 


la^rinarg,  benereal,  Skin. 


Roberts  on  Urinary  Diseases— Fourth  Edition. 

A  Practical  Treatise  on  Urinary  and  Eenal  Diseases, 
including  Urinary  Deposits.  By  Sir  William  Robeets,  M.  D., 
Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc.  Fourth 
American  from  the  fourth  London  edition.  In  one  handsome  octavo 
of  609  pages,  with  81  illustrations.     Cloth,  |3.50. 

The  peculiar  value  and  finish  of  the  book 
are  in  a  measure  derived  from  its  resolute 
maintenance  of  a  clinical  and  practical 
character.    It  is  an  unrivalled  exposition 


of  everything  which  relates  directly  or  in- 
directly  to   the   diagnosis,   prognosis   and 


treatment  of  urinary  diseases,  and  possesses 
a  completeness  not  found  elsewhere  in  our 
language  in  its  account  of  the  different 
at^aetions.— The  Ma7ichesier  Medical  Chroni- 
cle, July,  1885. 


Jackson  on  the  Skin— Just  Ready. 

The  Ready-Reference  Handbook  of  Skin  Diseases. 
By  Geoege  Thomas  Jackson",  M.  D.,  Professor  of  Dermatology,  Women's 
Medical  College,  New  York  Infirmary.  In  one  12mo.  volume  of  450  pages 
with  50  illustrations.     Cloth,  $2.75.     Just  ready. 

This  volume  is  devoted  to  the  art  of  dermatology,  to  the  practice  of  this 
department  of  medicine  in  its  latest  development.  No  attempt  has  been 
made  to  discuss  debatable  questions,  and  pathology  and  etiology  do  not 
receive  as  full  consideration  as  symptomatology,  diagnosis  and  treatment. 
The  alphabetical  arrangement  of  the  different  diseases  has  been  adopted  as 
conducive  to  the  greatest  possible  convenience  in  use.  The  pages  are 
illustrated  with  a  large  number  of  engravings,  many  being  photographic 
and  vivid  reproductions  of  actual  cases.  A  handsome  lithographic  frontis- 
piece adds  to  the  beauty  and  usefulness  of  a  volume  for  which  a  wide  recog- 
nition is  assured. 

Culver  &  Hayden  on  Venereal  Diseases. 

A  Manual  of  Venereal  Diseases.  By  E  M.  Cultee, 
M.  D.,  Pathologist  and  Assistant  Attending  Surgeon,  Manhattan  Hospital, 
New  York,  and  J.  R.  Hayden,  M.  D,,  Chief  of  Clinic  Venereal  Depart- 
ment, Yanderbilt  Clinic,  College  of  Physicians  and  Surgeons,  New  York. 
In  one  12mo.  volume  of  289  pages,  with  33  illustrations.     Cloth,  $1.75. 

Hyde  on  the  Skin— Second  Edition. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For 
the  use  of  Students  and  Practitioners.  By  J.  Nevins  Hyde,  A.M.,  M.D., 
Prof,  of  Dermatology  and  Venereal  Diseases  in  Eush  Med.  College,  Chicago. 
Second  edition.  In  one  handsome  octavo  volume  of  676  pages,  2  colored 
plates  and  85  beautiful  and  elaborate  illus.  Cloth,  $4.50;  leather,  $5.50. 
His  treatise  is  like  his  clinical  instruction,  into  his  book  all  the  best  of  that  which  the 
admirably  arranged,  attractive  in  diction  past  years  have  brought  forth.  The  pre- 
and  strikingly  practical  throughout.  No  scriptions  and  formulae  are  given  in  both 
clearer  description  of  the  lesions  of  the  skin  common  and  metric  systems.  Text  and 
is  to  be  met  with  anywhere.  Dr.  Hyde  has  illustrations  are  good,  and  colored  plates  of 
shown  himself  a  comprehensive  reader  of  rare  cases  lend  additional  attractions.— iJ/ed- 
the  latest  literature,  and  has  incorporated    ical  Press  of  Western  New  York,  June,  1888. 


(3^neto[o%]o, 


Thomas  &  Mund^  on  Women— Sixth  Edition. 

A  Practical  Treatise  on  the  Diseases  of  "Women, 
By  T.  Gatllaed  Thomas,  M.  D.,  LL.  D.,  Emeritus  Professor  of  Diseases 
of  Women  in  the  College  of  Physicians  and  Surgeons,  New  York,  and 
Paul  F.  Munde,  M.  D,,  Professor  of  Gynecology  in  the  New  York  Poly- 
<;linic.  New  (sixth)  edition,  thoroughly  revised  and  rewritten  by  Dr 
Mund6.  In  one  large  handsome  octayo  volume  of  824  pages,  with  347  illus- 
trations, of  which  201  are  new.     Cloth,  $5.00;  leather,  $6.00. 


Probably  no  treatise  ever  written  by  an 
American  author  on  a  medical  topic  has 
►been  accepted  by  more  practitioners,  as  a 
standard  text-book,  or  read  with  pleasure 
^nd  profit  by  more  medical  students  than 
Thomas  on  the  diseases  of  women.  This 
■volume  in  classic  excellence,  elegance  of  dic- 


tion and  scholarly  and  scientific  statement 
must  remain  what  it  long  has  been,  a  stand- 
ard text-book  both  for  practitioner  and  stu- 
dent, at  home  and  abroad,  and  an  enduring 
pride  to  American  gynecologists. — 27ie 
Brooklyn  Medical  Journal,  March,  1892. 


Davenport's  Non-Surgical  Gynecology— New  Ed. 

Diseases  of  Women,  a  Manual  of  Won- Surgical 
'Gynaecology.  Designed  especially  for  the  Use  of  Students  and  General 
Practitioners.  By  F.  H.  Davenpoet,  M.  D.,  Assistant  in  Gynaecology  in 
-the  Medical  Department  of  Harvard  University,  Boston.  New  (second) 
edition.  In  one  handsome  12mo.  volume  of  314  pages,  with  106  illustra- 
-tions.     Cloth,  $1.75.     Just  ready. 


Comparatively  few  practitioners  are  pre- 
3)ared  to  perform  the  graver  gynecological 
operations,  but  all  are  compelled  to  deal  with 
the  multitudinous  ailments  of  women,  and  in 
many  instances  non-surgical  measures  are 
-preferable,  though  neglected  by  those  whose 
■special  skill  has  enlarged  the  field  of  opera- 
i,ive  interference.    The  present  volume  deals 


with  nothing  which  has  not  stood  the  actual 
test  of  experience,  and  being  concisely  and 
clearly  written  it  conveys  a  great  amount 
©f  information  in  a  convenient  space.  The 
demand  for  two  editions  in  less  than  three 
years  confirms  its  usefulness. — The  Medical 
Brief,  August,  1892. 


May  on  Diseases  of  Women— Second  Edition. 

A  Manual  of  the  Diseases  of  Women.  Being  a  concise 
.and  systematic  exposition  of  the  theory  and  practice  of  Gynecology.  By 
-Chaeles  H.  May,  M.  D.,  late  House  Surgeon  to  Mount  Sinai  Hospital, 
JNew  York.   Second  edition,  edited  by  L.  S.Eau,  M.D.,  Attending  Gynecol- 

In  one  12mo.  volume  of  360  pages, 


ogist  at  the  Harlem  Hospital,  N.  Y. 
with  31  illustrations.     Cloth,  $1.75. 

This  is  a  manual  of  gynecology  in  a  very 
■condensed  form,  and  the  fact  that  a  second 
edition  has  been  called  for  indicates  that  it 
has  met  with  a  favorable  reception.  It  is 
intended,  the  author  tells  us,  to  aid  the  stu- 
•dent  who  after  having  carefully  perused  lar- 


ger works  desires  to  review  the  subject,  and 
he  adds  that  it  may  be  useful  to  the  prac- 
titioner who  wishes  to  refresh  his  memory 
rapidly  but  has  not  the  time  to  consult  lar- 
ger wo7ks. — The  Physician  and  Surgeon, 
June,  1890. 


(Obstetrics. 


Parvin's  Obstetrics— Second  Edition. 

The  Science  and  Art  of  Obstetrics.  By  Theophilus 
Paevin,  M.  D.,  LL.  D.,  Professor  of  Obstetrics  and  the  Diseases  of  Women 
and  Children  in  Jefferson  Medical  College,  Philadelphia.  Second  edition. 
In  one  handsome  8vo.  volume  of  701  pages,  with  239  engravings  and  a 
colored  plate.     Cloth,  $4.25  ;  leather,  $5.25. 


The  second  edition  of  this  work  is  fully 
op  to  the  present  state  of  advancement  of 
the  obstetric  art.  Rarely  in  the  range  of  ob- 
stetric literature  can  be  found  a  work  which 
is  so  comprehensive  and  yet  compact  and 
practical,    In  such  respect  it  is  essentially  a 


text-book  of  the  first  merit.  The  treatment 
of  the  subject  gives  a  real  value  to  the  work 
— the  individualities  of  a  practical  teacher, 
a  skilful  obstetrician,  a  close  thinker  and  a 
ripe  scholai.— Medical  Hecord,  Jan.  17, 1891. 


Playfair's  Midwifery— Seventh  Edition. 

A  Treatise  on  the  Science  and  Practice  of  Mid- 
wifery, By  W.  S.  Playfair,  M.  D.,  F.  R.  C.  P.,  Professor  of  Obstetric 
Medicine  in  King's  College,  London,  etc.  Fifth  American,  from  the 
seventh  English  edition.  Edited,  with  additions,  by  Robert  P.  Harris, 
M.  D.  In  one  handsome  octavo  volume  of  664  pages,  with  207  engravings 
and  5  plates.     Cloth,  $4.00  ;  leather,  $5.00. 

Truly  a  wonderful  book;  an  epitome  of  all 
obstetrical  knowledge,  full,  clear  and  con- 
cise.  In  thirteen  years  it  has  reached  seven 


editions.  It  is  perhaps  the  most  popular 
work  of  its  kind  ever  presented  to  the  pro- 
fession. Beginning  with  the  anatomy  and 
physiology  of  the  organs  concerned,  nothing 
is  left  un  written  that  the  practical  accoucheur 
should  know.  It  seems  that  every  conceiv- 
able physiological  or  pathological  condition 


from  the  moment  of  conception  to  the  time 
of  complete  involution  has  had  the  author's 
patient  attention.  The  plates  and  illustra- 
tions, carefully  studied,  will  teach  the  sci- 
ence of  midwifery.  The  reader  of  this  book 
will  have  before  him  the  very  latest  and  best 
of  obstetric  practice,  and  also  of  all  the 
coincident  troubles  connected  therewith. — 
Southern  Fractitioner,  December,  1889. 


King's  Obstetrics— New  Edition.    Just  Ready. 

A  Manual  of  Obstetrics.  By  A.  F.  A.  King,  M.  D.,  Pro- 
fessor of  Obstetrics  and  Diseases  of  Women  in  the  Medical  Department  of 
the  Columbian  University,  Washington,  D.  C,  and  in  the  University  of 
Vermont,  etc.  New  (Fifth)  edition.  In  one  12mo.  volume  of  450  pages, 
with  150  illustrations.  Cloth,  $2.50.  Just  ready 
A  notice  of  the  previous  edition  is  appended. 
Dr.  King,  in  the  preface  to  the  first  edition 
of  this  manual,  modestly  states  that  "its 
purpose  is  to  furnish  a  good  groundwork  to 


the  student  at  the  beginning  of  his  obstetric 
studies."  Its  purpose  is  attained;  it  will 
furnish  a  good  groundwork  to  the  student 
who  carefully  reads  it;  and  further,  the 
busy  practitioner  should  not  scorn  the  vol- 
ume because  written  for  students,  as  it  con- 


tains much  valuable  obstetric  knowledge, 
some  of  which  is  not  found  in  more  elabor- 
ate text-books.  Of  the  141  illustrations  it 
may  be  safely  said  that  they  all  illustrate, 
and  that  the  engraver's  work  is  excellent. 
From  everv  standpoint  we  can  most  heart- 
ily recommend  the  book  both  to  practi- 
tioner and  student. — The  Medical  News, 
December  7, 1889. 


Smith  on  Children— Seventh  Edition. 

A  Treatise  on  the  Diseases  of  Infancy  and  Child- 
hood. By  J.  Lewis  Smith,  M.  D.,  Clinical  Professor  of  Diseases  of 
Children  in  the  Bellevue  Hospital  Medical  College,  N.  Y.  New  (seventh) 
edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  vol- 
ume of  881  pages,  with  51  illustrations.    Cloth,  $4.50;  leather,  |5.50, 

We  have  always  considered  Dr.  Smith's 
book  as  one  of  the  very  best  on  the  subject. 
It  has  always  been  practical— a  field  book, 


theoretical  where  theory  has  been  deduced 
from  practical  experience.  One  seldom  fails 
to  find  here  a  practical  suggestion  after 
search  in  other  works  has  been  in  vain.  In  the 
seventh  edition  we  note  a  variety  of  changes 


la  accordance  with  the  progress  of  the  times. 
It  still  stands  foremost  as  the  American  text- 
book. The  literary  style  could  not  be  ex- 
celled, its  advice  is  always  conservative  and 
thorough,  and  the  evidence  of  research  has 
long  since  placed  its  author  in  the  front 
rank  of  medical  teachers. — The  American. 
Journal  of  the  Medical  Sciences,  Dec.  1891. 


Taylor's  Medical  Jurisprndence— New  Edition. 

A  Manual  of  Medical  Jurisprudence.  By  Alfeed  S. 
Tayloe,  M.  D.,  Lecturer  on  Medical  Jurisprudence  and  Chemistry  in 
Guy's  Hospital,  London.  New  American  from  the  twelfth  English  edi- 
tion. Thoroughly  revised  by  Claek  Bell,  Esq.  ,  of  the  New  York  Bar. 
In  one  large  octavo  volume  of  about  900  pages,  with  illustrations.     Shortly, 


Subscription  Price  Reduced  to  $4.00  Per  Annum. 

THE  flEblCflL  NEW5. 

That  The  News  fulfils  the  wants  of  men  in  active  practice  is  made 
clear  by  the  steady  growth  of  its  subscription  list.  This  increase  of  readers 
has  rendered  possible  a  reduction  in  the  price  of  The  News  to  Four 
Dollars  per  year,  so  that  it  is  now  by  far  the  cheapest  as  well  as  the 
best  large  weekly  journal  published  in  America. 

In  a  word  The  Medical  News  is  a  crisp,  fresh,  weekly  newspaper 
and  as  such  occupies  a  well-marked  sphere  of  usefulness,  distinct  and  com- 
plementary to  the  ideal  monthly  magazine.  The  Ameeican  Jouenal  of 
THE  Medical  Sciences. 


T|e  American  Joai"naI  o!  the  EJedical  ^oienee^, 

Published  Monthly,  at  $4.00.  Per  Annum. 

Being  the  medium  chosen  by  the  best  minds  of  the  profession  during 
this  period  for  the  presentation  of  their  ablest  papers.  The  Ameeican 
Jouenal  has  well  earned  the  praise  accorded  it  by  an  unquestioned 
authority — "from  this  file  alone,  were  all  other  publications  of  the  press 
for  the  last  fifty  years  destroyed,  it  would  be  possible  to  reproduce  the 
great  majority  of  the  real  contributions  of  the  world  to  medical  science 
during  that  period. " 


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